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HAY- FEVER 

ITS PREVENTION AND CURE 



Orifice of middle ethmoidal cells 
Superior turbinal bone 
Orifice of the posterior ethmoidal cells 

Orifice of the sphenoidal sinus 
Sphenoidal sinus 



Frontal sinus 




Orifice of 
frontal sinus 

Upper orifice 
of nasal duct 



Orifice of Eustachian 
tube 



Lower orifice of 
nasal duct 



Middle turbinal bone 

Inferior turbinal bone Orifice of the antrum Orifice of infundibulu 



Section of the Nose, showing the Turbinal Bones and Meatuses 
with the Openings in Dotted Outline 
(After Morns' "Text-Book of Anatomy."') 



HAY-FEVER 



ITS PREVENTION AND CURE 



BY 

W. C. HOLLOPETER, A.M., M.D., LL.D. 

ATTENDING PHYSICIAN ST. JOSEPH'S HOSPITAL; PEDIATRICIAN TO 
THE PHILADELPHIA GENERAL HOSPITAL; PROFESSOR PEDIATRICS, 
EMERITUS, MEDICO-CHIRURGICAL COLLEGE; EX-PRESIDENT 
OP THE ASSOCIATION OF AMERICAN TEACHERS OF THE 
DISEASES OF CHILDREN; EX-CHAIRMAN OF THE SEC- 
TION ON DISEASES OF CHILDREN, AMERICAN 
MEDICAL ASSOCIATION; MEMBER OF AMERI- 
CAN ACADEMY OF MEDICINE, ETC. 




FUNK & WAGNALLS COMPANY 

NEW YORK AND LONDON 

1916 



IV6 



Copyright, 1916, by 

FUNK & WAGNALLS COMPANY 

Copyright under the Articles of the Copyright Convention 

of the Pan-American Republics and the United 

States, August 11, 1910 

[Printed in the United States of America] 



Published, July, 1916 




AUG -2 1916 



^>CI.A437083 



CONTENTS 

PAGE 

Preface vii 

Introduction ix 



PART I 
WHAT HAY-FEVER IS. HISTORY, PERIOD- 
ICITY, SYMPTOMS AND DIAGNOSIS 

1. Definition, History and Bibliography 19 

2. Causes 38 

3. Periodicity 46 

4. Symptoms 53 

5. Its Pathology, Diagnosis and Prognosis 65 

PART II 
ACCEPTED CAUSES 

1. When Due to Some Exciting Agent Such as 

Pollen 87 

2. The Predisposing Causes 110 

PART III 
FORMS OF TREATMENT 

1. Preventive Measures 147 

2. Local Treatment by Nasal Applications.... 167 

3. As to Diet, Exercise and Rest 178 

4. When Asthma Occurs as a Sequel 185 

[v] 



CONTENTS 

*AG1 

5. The Use of Serums — Dunbab's Sebum . . 191 

6. Experiments with Autosebum. By Harold 

Hays, M.D 238 

7. Db. E. T. Manning's Views 254 

8. The Use of Phylacogen. By I. H. Alexander, 

M.D 258 

9. The Calcium Salt Treatment. By Harold 

Wilson, M.D 261 

10. The Pollen Thebapy Treatment. By J. L. 

Goodale 274 

11. Subgical Tbeatment 285 

12. A Summaby of Tbeatment 286 

BlBUOGBAPHY 293 

Index ....... 337 



1*1 1 



PREFACE 

Having had remarkable and uniform 
success with a simple treatment of hay- 
fever for the last twenty years, during 
which time I have given complete relief 
to many patients in my private practise, 
and having made a thoro clinical study 
of this affection, as well as an exhaustive 
review of the literature relative to it, I 
feel justified in presenting the results of 
my labors in this short treatise. 

There is little to be said definitely about 
the etiology of the disease. It is undoubt- 
edly caused by an external irritant, pos- 
sibly containing a micro-organism or a 
toxin, which becomes especially active in 
the nasal passages of an individual pre- 
disposed by systemic debility or local 

[viil 



PREFACE 

abnormality. We acknowledge the ele- 
ment of neurotic disturbance, but to dog- 
matically define its exact cause and modus 
operandi is beyond us. 

In order that the best thought of the 
subject may be presented to the reader, 
I have compiled, arranged, and annotated 
the most worthy literature, and I acknowl- 
edge my indebtedness to the many writers 
quoted. The most of my original com- 
munication is devoted to the all-important 
point in the discussion — the successful 
treatment A complete bibliography is 
appended. 

W. C. HOLLOPETER. 



[▼ui] 



INTEODUCTION 

Hay-eever has become so well-known 
and is so universal a disease that many 
State organizations have been formed for 
its careful study; we are thus hopeful of 
some positive developments in the better 
management of hay-fever by concerted 
effort of the sanitarian and physician. 
The choice of a name has not been very 
fortunate, as it has been discovered that 
hay in itself has very little, or nothing, to 
do with the cause. I give, however, a few 
synonyms in the early part of the book. 

Next to tuberculosis, hay-fever is one 
of the most interesting and common dis- 
eases, and has received an enormous 
amount of study. While it is not directly 
fatal, it is exceedingly distressing and is 

[ix] 



INTRODUCTION 

certain by its annual visitation to lower 
the vital resistance and induce other ill- 
ness in the body. In this way it becomes 
a prolonged and serious menace to the 
comfort and happiness of the sufferer. 
Hay-fever was not regarded frequent in 
the young until a more careful study of 
autumnal and spring catarrhs among neu- 
rotic children revealed the fact that the 
same troublesome complaint had occurred 
the previous season. The frequency of 
"cold taking" among children is due to 
their lowered vitality, the result being 
adenoids and enlarged tonsils which often 
precede the typical hay-fever. 

It has been found that children, espe- 
cially the neurotic offspring of nervous 
parents, are as subject to hay-fever as 
adults, if not more so, for we certainly 
have an ever-enlarging army of catarrhal 
children. There is no doubt that in every 
[x] 



INTRODUCTION 

class hay-fever is decidedly on the in- 
crease in America. True hay-fever is 
also found in great masses of thoughtful 
adults, who are prone to forget the previ- 
ous attacks, altho they may have had many 
annual visitations of the disorder. Some 
slight exposure or irregularity of diet, or 
an unusual change in the atmosphere, suf- 
fice to explain the indisposition, and satis- 
fies the mind for the time. It is certain 
that a large number of hay-fever sufferers 
forget from year to year the annual visita- 
tion ; this is more likely if the attack has 
not been severe. Furthermore, it has been 
most conclusively proved by many authori- 
ties that hay-fever does not occur unless 
we have a conjunction of three necessary 
factors : 

1. An external air-borne irritant. 

2. A sensitive or diseased nasal mucous 
membrane. 



INTRODUCTION 

3. An unstable nerve-center. 

Upon the simultaneous manifestation of 
these three factors in any individual we 
are reasonably sure in making a diagnosis 
of hay-fever. An absence of any one of the 
three admits at once of distinct doubt. 

The claim for originality in this thesis 
lies in the fact that the author recognizes 
the three essential factors, as stated above, 
as the cause of hay-fever and claiming 
that the remedy lies in controlling or de- 
stroying the habit, by inhibiting or be- 
numbing the sensitive nasal surface by 
local cleansing and massage. The litera- 
ture of hay-fever has grown so very pro- 
lifically in the last five years that to follow 
it out in detail would be a difficult and use- 
less task. Most writers agree as to the 
three essential causative factors, and vol- 
umes have been written in discussion of 
their different phases, 
[xli] 



INTRODUCTION 

Dr. Geo. M. Beard, one of the earlier 
and most exhaustive writers, regards it as 
a neurosis, due to an unstable brain-center, 
and a functional disease of the nervous 
system, thus ignoring all environment, 
climate and nasal conditions. Sajous, on 
the other hand, regards the trouble as one 
of local origin, ignoring heredity and neu- 
rosis, and finds an abnormal nasal chamber 
in all active cases. They both concede ex- 
ternal irritants as essentially necessary to 
the initial paroxysm, but regard this of 
secondary importance. It was not until 
Prof. Dunbar and his followers made their 
exhaustive studies of pollen that we ar- 
rived at any satisfactory scientific knowl- 
edge as to the exact nature of this "ex- 
ternal irritant/ ' and applied the antidote 
for its control. Literature on hay-fever 
during the past ten years has centered 
largely on discussion of these studies. It 

[ xiii ] 



INTRODUCTION 

is for this reason that I have given Dun- 
bar so large a space in my book. I have 
allowed him to speak for himself. 

In my first published paper in 1898, I 
stated that I had succeeded in controlling 
a large number of cases by "scrubbing 
most carefully every portion of the mu- 
cous membrane of the nasal chamber, be- 
ing sure to reach between the turbinated 
bones and all around any slight promi- 
nence." Musser and Kelly ("Practical 
Treatment," 1913, Saunders, Philadel- 
phia) quote E. W. Wright as placing 
great stress upon the hypersensitive condi- 
tion of the nasal mucosa as the important 
causative factor in many cases, suggest- 
ing a frictional massage of the mucous 
membrane of the nose in order to in- 
crease its resisting powers, so that it can 
withstand the irritation and excitation 
from the impact of the pollen of plants, 
[xiv] 



INTRODUCTION 

His method is to apply gentle massage 
to the nasal mucous membrane through 
the medium of a cotton-covered probe. 
These applications are to be made daily 
for from three to five minutes in each 
nasal chamber. 

I am unable to find any additional au- 
thority for this method of management of 
the disease. The observation of Wright 
was made long after the publication of 
my paper ; and certainly priority for such 
local treatment belongs to me. 



TxtT 



PART I 

WHAT HAY-FEVEE IS 

HISTOEY, PERIODICITY SYMPTOMS 
AND DIAGNOSIS 



[17] 



PART I 
WHAT HAY-FEVER IS 

HISTORY, PERIODICITY, SYMPTOMS 
AND DIAGNOSIS 

1. Definition, History and Bibliography 

Among the synonyms that have been 
employed for the term hay-fever may be 
named the following: Autumnal catarrh, 
Bostock's catarrh, coryza vasomotoria, 
coryza vasomotoria periodica, hay-asthma, 
idiosyncratic coryza, June cold, July cold, 
nervons coryza, nervous catarrh, paroxys- 
mal sneezing, peach cold, periodic hyper- 
esthetic rhinitis, pollen catarrh, pollen 
poisoning, pruritic catarrh, pruritic rhi- 
nitis, ragweed fever, rhinitis sympathetica, 
rhinitis vasomotoria, rose catarrh, rose 

[19] 



HAY-FEVER 

cold, summer bronchitis, summer catarrh, 
summer catarrh from idiosyncrasy, sum- 
mer fever, typical early summer catarrh, 
vasomotor coryza, vasomotor rhinitis. In 
other language are the following equiva- 
lents: Latin — Catarrhus sestivus, coryza 
vasomotoria periodica; French — Catarrhe 
d'ete, catarrhe de foin; German — Friih- 
sommerkatarrh, Heuasthma, Heufieber ; 
Italian — Asma dei mietitori, febbre del 
fieno, asma del fieno. 

The term "hay-fever" was first used to 
designate the form of disease occurring in 
the autumn in distinction from like affec- 
tions which occur in other seasons. So 
universal, however, has become its use that 
it is now employed to designate all the 
forms of what may be called the periodic 
influenzas, irrespective of seasons. 

Hay-fever may be defined as an affec- 
tion of the upper air-passages occurring 

[20] 



WHAT HAY-FEVER IS 

periodically, usually at or near a fixt 
date in the early autumn, sometimes in the 
spring or summer, characterized by its 
sudden onset and as sudden termination in 
certain atmospheric conditions, by swell- 
ing and turgescence of mucous membranes 
of the nasal fossae and adjacent cavities, 
irritating discharges therefrom, and vari- 
ous symptoms of coryza, and occasionally 
by asthmatic paroxysms. It always re- 
sults from the combination of a special 
predisposition, from depraved resistance 
or lowered vitality of the general system 
or a local lesion, and an exciting cause, 
believed to be a micro-organism or pecu- 
liar toxin, generally arising from pollen 
or dust deposited upon or in the mucous 
membrane of the upper air-passages. The 
important predisposing causes are : hered- 
ity, idiosyncrasy, neurotic temperament, 
peculiar susceptibility of the vasomotor 
1 21 1 



HAY-FEVER 

system, generally debilitated condition, 
deranged assimilation, and a local lesion. 
Hay-fever has been defined as a neurosis, 
as an idiosyncrasy, as a catarrhal affec- 
tion, and as a type of influenza, and as 
various combinations of these. The de- 
position of some special irritant is uni- 
versally regarded as the exciting cause. 

Exactly when hay-fever was recognized 
as a distinct affection is not known. Bes- 
chorner shows that it was known in the 
sixteenth century. In 1565 Botallus re- 
ported a case. Van Helmont and Binnin- 
ger, in the seventeenth century, speak of 
it. A similar distressing catarrhal affec- 
tion, but due to the rose, is instanced in 
"Acta nat. curios. Ephemerides," Dec. 
II, Ann. V, obs. 22, and again in the same 
journal, Dec. Ill, Ann. V and VI, obs. 
193, a case of annually recurring profuse 
nasal catarrh is mentioned. John Floyer, 

[22] 



WHAT HAY-FEVER IS 

London, 1698, noticed that there were 
peculiar cases of asthma in which the at- 
tacks were longer and more acute in sum- 
mer than in winter. In Good's " Study 
of Medicine" there is a reference to a 
case related by Timseus in 1667, of an at- 
tack of an asthmatic nature caused by the 
odor of roses and ipecac. Eiedlin, in his 
"Lin. Med.," p. 177, in 1695, wrote of the 
odor of roses causing a catarrh of the 
head, resembling hay-fever. C. L. Parry, 
of London, records a case in 1809 and an- 
other in 1811. Elliotson, in 1821, tells of 
a patient who had had hay-fever since 
1789, and of another who was si&ty-six 
years of age and who had had the disease 
from his seventh year, i.e., since 1755, and 
of a third who had been afflicted for many 
years. 

Just when and where the term "hay- 
fever" or "hay-asthma" arose it is im- 

[23] 



HAY-FEVER 

possible to say, but probably it was popu- 
larly so named. The emanations from dry 
hay were first thought to have caused it. 
Dr. Bostock, who was himself a sufferer, 
in 1819, found that the laity knew of the 
affection, altho it was not recognized 
as a distinct disease by the profession. 
He objected to the term "hay-fever,' ' 
which was already employed to designate 
it in his day, contending that moist heat, 
sunshine, dust, and fatigue were more 
potent in its causation than emanations 
from dry hay. It seems remarkable that 
the profession in England were unfamiliar 
with hay-fever as a distinct affliction, es- 
pecially as their king, George IV, was a 
sufferer from it. In 1828, Bostock, who 
had first described the disease to the 
Medico-Chirurgical Society of London as 
a "case of a periodic affection of the eyes 
and chest,' f published some further ob- 

[24] 



WHAT HAY-FEVER IS 

servations on the complaint under the 
title "Summer Catarrh/ ' or "Catarrhus 
r ^stivus." In 1828, MacCulloch included 
it in his "An Essay on the Remittent and 
Intermittent Diseases/ J but advanced no 
special views. In 1830, Augustus Prater 
published notes of a case seen in Paris. 
In 1831, Dr. Elliotson, in London, briefly 
described the affection; and in 1833 he 
discust the complaint more fully and 
opposed Bostoek's theory of heat and re- 
jected the hay-theory of its origin, but 
declared grasses to be more important 
factors; and he first pointed to pollen as 
the probable cause of the disease. In 1847, 
Dr. Ramadge detailed reports of cases and 
believed "effluvia from flower s" caused it. 
In 1850, Gream first alluded to dust as an 
exciting cause and proposed nux vomica 
as a remedy. In 1852 Dr. Laforgue, of 
Toulouse, wrote his essay "Observation 

[25] 



HAY-FEVER 

de catarrhe d'ete," in which he upheld 
heat as the cause, after the view of Bos- 
tock. But in the next year, 1853, in 
"L'Abeille Medicale," an anonymous con- 
tributor, reciting his own case, advocated 
hay-emanations and not heat as the excit- 
ing agent. In 1854 Phoebus, of Giessen, 
concluded from his study of 154 cases that 
sunlight was the active cause of the at- 
tacks. In 1857 Watson ascribed the mal- 
ady to the presence of vegetable matter 
in the atmosphere. In 1859 Phoebus again 
published the results of his circular of in- 
quiry. He went into the subject more 
thoroughly than any of his predecessors, 
and from sunlight he shifted to ozone as 
the theoretic cause of the malady. In this 
same year Hyde Salter named as the ex- 
citing agents "bright, hot, dusty sun- 
shine/ ' a full meal, and hay, and recited 
two interesting cases. Another writer, 

[26] 



WHAT HAY-FEVER IS 

Walshe, in the same year, referred to hay- 
fever as a singular variety of nasopul- 
monary catarrh, and he first called atten- 
tion to the fact that the disease, in his own 
person, "always disappeared in crossing 
the Atlantic." 

In July, 1860, Dr. Cornaz, of Neufchatel, 
Switzerland, in a paper on hay-fever, de- 
scribed six cases, and concluded that the 
flowers of grasses were the cause of the 
disease, and he was followed on the 20th 
of August of the same year by Dr. La- 
bosse, of Nitry, France, in a paper en- 
titled "Nouvelle observation de catarrhe 
de foin," in which he spoke of three per- 
sons whose symptoms occurred at the time 
certain flowers were in bloom. In 1866 
strong light and great heat were advanced 
as aggravating causes by Br. "Wm. 'Ab- 
botts Smith. In his published work, "On 
Hay-fever, Hay-asthma, or Summer Ca- 

[27] 



HAY-FEVER 

tarrh," he rejected the ozone theory of 
Phoebus. 

I In 1867 the nervous origin of the dis- 
ease was first advanced by Dr. William 
Pirrie, who spoke of two forms, — one a 
spasmodic form caused by external irri- 
tants, the other arising from the action of 
light and heat upon the central nervous, 
the cerebrospinal, and sympathetic sys- 
tems. In the same year, Helmholtz, who, 
tho not a general practitioner, while 
suffering from hay-fever, began to treat 
it with a quinin solution and found that 
he was relieved thereby. Two years later 
he detailed to C. Binz, of Bonn, Germany, 
by letter, the history of his sufferings, and 
recommending his solution as a ready 
means of relief and even of prevention, 
which was in accord with the findings of 
Binz that the quinin solution was poison- 
ous to infusoria. In this letter Helmholtz 

[28] 



WHAT HAY-FEVER IS - 

propounded the theory that the .symp- 
toms were caused by vibrios which, tho 
latent at other times in the nasal fossae 
and sinuses, were excited to activity by 
the heat of summer. It has since been 
thought that the organisms found by 
Helmholtz, by means of the microscope, 
in the nasal discharges during an attack 
were probably fragments of mycelium-like 
threads which develop from pollen-cells 
under the influence of the heat and mois- 
ture of the nasal chambers and which con- 
tain the minute fovilla of the pollen-cells. 
The use of the quinin solution which Helm- 
holtz so successfully employed on himself 
became very popular and found many 
strong advocates in the profession until 
the extensive researches of Blackley in re- 
gard to pollen in 1873. In the meantime, 
in 1870, Dr. George Moore advocated a 
complex theory of the disease, really com- 

[29] 



HAY-FEVER 

binations of preceding theories. In the 
same year Roberts issued a short, practi- 
cal paper, claiming to be the first to ob- 
serve excessive coldness of the tip of the 
nose as the " pathognomonic' ' symptom 
of hay-fever and desiring credit to be 
accorded him for this discovery. 
t In 1872, Morrill Wyman, of Cambridge, 
Mass., distinguished two different forms 
of the disease; naming that occurring in 
August "autumnal catarrh," peculiar to 
America, and that of the spring or early 
summer "June cold" or "rose-cold," more 
prevalent in England. 

Dr. Wyman first attempted to define the 
geographical limits of the disease, and 
called attention to the important fact 
that residence in certain elevated regions 
brought certain and complete relief in 
most cases of autumnal catarrh. He 
stated that a lady from Lynn, Mass., a 

[30] 



WHAT HAY-FEVER IS 

great sufferer, accidentally observed in 
1853 that her catarrh passed by while she 
was traveling in the White Mountains, 
and that for the following ten years she 
visited the region and escaped the disease. 
In 1860, Jacob Horton, of Newburyport, 
Mass., wrote Dr. Wyman that the White 
Mountains gave the only relief. In 1873, 
Charles H. Blackley, of Manchester, en- 
deavored to show that pollen mainly, if 
not exclusively, caused the malady, and 
by extensive experiments showed that the 
amount of pollen in the atmosphere at 
great elevations was to that in the air at 
ordinary breathing levels as nineteen to 
one. He proved, by very ingenious and 
carefully conducted series of experiments, 
that the pollen of grasses and flowers was 
the sole cause of hay-fever in himself, and 
that in two other patients the severity of 
the attacks was directly related to the 

[31] 



HAY-FEVEE 

amount of pollen in the air. His sub- 
sequent ' observations made it extremely 
probable that pollen is an important factor 
in the causation of hay-fever, altho all 
kinds of dust may be sufficiently irritating 
to excite the paroxysms. This was in op- 
position to the views of Phoebus and of 
Pirrie, both of whom suggested heat, 
strong light, and ozone as the exciting 
causes. Pirrie had also suggested disturb- 
ance of the central nervous system as an 
important etiologic factor. He was sup- 
ported in this view in 1876 by Morrill Wy- 
man, then of New York. In the same year 
Beard, of New York, published his mono- 
graph, the information for which had been 
painstakingly gathered from replies to 
two hundred circulars which he had issued 
to medical men all over America, some- 
what after the manner of Phcebus; al- 
tho, unlike Phoebus, Beard had himself 

[32] 



WHAT HAY-FEVER IS 

seen and treated many cases. From his 
data he drew the conclusion that the im- 
mediate exciting causes were more than 
thirty in number, and that secondary 
causes might increase this list to more 
than one hundred. He showed also from 
his statistics that the nervous tempera- 
ment existed in a great proportion of the 
sufferers, and that nerve tonics were of 
some value. In 1877, Marsh, of Tuckerton, 
New Jersey, published an essay in which 
he accepted completely the pollen theory. 
He first called attention, in this paper, to 
the activity of the pollen of Ambrosia 
artemisicefolia, or common ragweed, as 
by far the most active of the pollens in 
America in producing the attacks. 
: In 1882, Daly, of Pittsburgh, first called 
attention to the fact that a diseased con- 
dition of the nasal cavities was an impor- 
tant factor in the production of the exacer- 

[33] 



HAY-FEVER 

bations of the disease. Roe, of Rochester, 
in 1883, advocated the same theory, but 
added that "removal of the diseased tissue 
removes susceptibility to future attacks." 
In the same year, Sajous' essay appeared 
in which he advanced idiosyncrasy as a 
heretofore unconsidered element in the 
cause of hay-fever, and laid stress upon 
the three essential factors in the produc- 
tion of an attack; viz., first, an external 
irritant, second, a predisposition of the 
system, and, third, a vulnerable or sen- 
sitive area. In 1883, Hack accepted the 
local theory of the causation of the dis- 
ease. In 1884, Harrison Allen, of Phila- 
delphia, attributed the affection to a per- 
manent or temporary obstruction of one 
or both nasal chambers. In tlie same year, 
J. N*. Mackenzie, of Baltimore, termed the 
disease "coryza vasomotoria periodica," 
because it is essentially a coryza. He 

[34] 



WHAT HAY-FEVER IS 

says: "The well-recognized, but imper- 
fectly understood personal susceptibility to 
certain forms of local irritation, which is 
the sad prerogative of sufferers from this 
disease, has always been the stumbling- 
block in its investigation and the rock 
upon which the various speculations as to 
its nature have been wrecked." He dem- 
onstrated that "there exists in the nose a 
well-defined sensitive area whose stimu- 
lation, through a pathologic process or 
through db extra irritation, is capable of 
producing an excitation which finds its ex- 
pression in a reflex act or in a series of 
reflected phenomena." He thus claimed 
functional derangement of nerve-centers 
as essential to the disease. It was also in 
1884 that Sir Morell Mackenzie asserted 
that the universal cause of the disease was 
pollen, altho he did not deny that other 

irritating particles, e.g., ipecac, if per- 
[35] 



HAY-FEVER 

sistently brought in contact with the mu- 
cous membrane of the nasal chambers, 
may produce it. 

In 1885 Seth S. Bishop advocated the 
uric acid theory of the origin of the dis- 
ease. 

In 1887 Sir Andrew Clark, in the Caven- 
dish Lecture in London, emphasized the 
doctrine of the three great causative fac- 
tors, — viz., first an exciting agent, gener- 
ally pollen; second, the neurotic habit; 
and, third, a local morbid condition of the 
nasal mucous membrane. 

Since then many articles have appeared 
upon the subject, but no striking innova- 
tions in the possible etiology of hay-fever 
have been offered. 

In 1893, Macdonald said, we ought not 
to describe hay-fever as a disease but 
merely as a train of symptoms — a train 
of physiologic reflexes instigated by an 

[36] 



WHAT HAY-FEVER IS 

unwarrantably small provocation in cer- 
tain individuals more susceptible to the 
influence thereof than the rest of their 
kind. 

Early in 1897, Grayson, of Philadelphia, 
stated that "the neurotic habit may exist 
but is not essential to the disease, and the 
nervous system is implicated as a victim, 
not as a culprit," He claimed that hay- 
fever is a defect, not of the nervous, but 
of the nutritive system, believing that the 
digestive tract is the cradle of the sys- 
temic error. 

In October, 1897, Edmund W. Holmes, 
of Philadelphia, stated his belief to be 
that hay-fever was largely a neurosis, 
originating in local disease of the naso- 
pharynx, the characteristic manifestations 
being in part direct, the result of central 
nervous modifications, and in part reflex, 
from the action of various mechanical ir- 

[37] 



HAY-FEVER 

ritants, aided by local and constitutional 
factors when they exist, and by seasonable 
and climatic influences, the periodic and 
peripheric susceptibility being in partic- 
ular expressions of certain impressions. 

2. Causes 

The idea of an external irritant in hay- 
fever pervades most views of it. There 
can be no doubt, however, that there is 
usually an underlying systemic condition 
which renders individuals susceptible to 
the disease. It may, in addition, be ac- 
cepted as conclusive that the nasal ab- 
normalities found in hay-fever subjects 
are as often incidental as causative. They 
are seldom exclusively provocative of the 
susceptibility, and they are not the results 
of repeated attacks. Exactly what this 
underlying condition of susceptibility is 

has been variously regarded. The nature 
[38] 



WHAT HAY-FEVER IS 

of the irritant has been widely and scien- 
tifically investigated. While all theories 
advanced are in part more or less tenable, 
none of them alone is satisfactory. The 
condition is always, however, one of low- 
ered resistance, general or local. If gen- 
eral, it may be of neurotic, lithemic, idio- 
syncratic, gastric, intestinal, or diathetic 
origin. It is, therefore, my belief, that in 
hay-fever there is always, first, an excit- 
ing agent, and, second, a system predis- 
posed by debility of some character to the 
influence of this irritant. The overwhelm- 
ing testimony as to the character of this 
irritant points to its derivation from some- 
thing external to the body of the sufferer. 
Moreover, it is absolutely certain that 
without the action of an external irritant 
genuine hay-fever does not occur. The 
elaborate and ingenious experiments of 
Blackley, not only upon himself but upon 

[39] 



HAY-FEVER 

other individuals, clearly indicated the 
pollen of flowering plants as an active, 
exciting cause. It has never been shown 
that, altho pollen, healthy or unhealthy, 
may be a mechanical irritant and thus 
account for many cases, it is not also 
a chemic irritant when it has fallen upon 
a susceptible soil. It has been claimed 
that hay-fever is caused by a toxin gener- 
ated by a fermentative process in the 
pollen which has fallen into the alkaline 
solution of the nose; and it has been 
shown that acid solutions stop the move- 
ments of many micro-organisms and sper- 
matozoa, and that alkaline solutions in 
the nares have given little or no benefit in 
attacks of hay-fever. It has also been 
shown that the affection is more com- 
mon among men than among women, and 
that the blood of the latter is the less 
alkaline. 

[40 j 



WHAT HAY-FEVER IS 

Arnold, in 1896, stated that just what 
constitutes the irritant is not determined, 
and said it is likely that not healthy pollen 
but some fungoid growth is responsible, 
since threshers of grain, at other times 
without ill-effects, have complained of at- 
tacks of hay-fever after threshing smutty 
or moldy grain, especially oats. 

Helmholtz, himself a sufferer from hay- 
fever, discovered peculiar micro-organ- 
isms in his nasal discharges. These vib- 
rios were never found by others, and this 
fact is supposed to controvert his theory. 
It has not been shown conclusively that 
they have been sought for by other inves- 
tigators, and it is likely that they have 
not, since attention has been called away 
by the pollen and other theories. The 
antiseptic quinin solution employed by 
Helmholtz, while extensively used with 
good results for the subsequent decade, 

[41] 



HAY-FEVEK 

was not invariably accompanied by re- 
lief. Later, the relief that was given by 
quinin solutions was said to be psychic. 
This allegation may well be understood 
when it is considered that many other 
theories as to the causation of hay-fever, 
particularly the pollen, abounded soon 
after Helmholtz's expositions. 

Some very interesting investigations by 
Strangways, of St. Louis, in 1897, urged 
him to conclude the amount of pollen in 
the air is altogether too small to have an 
injurious mechanical, medicinal, or poi- 
sonous influence. He calculates that for 
every square foot of surface there is one 
ragweed, and inquiry showed that mere 
elevation of several hundred feet above 
the earth's surface does not give relief 
from this distressing affection. Strang- 
ways found that ragweed pollen proba- 
bly floats to 1,000 feet elevation ; but, if the 

[42] 



WHAT HAY-FEVER IS 

limit is placed at 500 feet, it would give 
for every plant 500,000 cubic feet of air, 
not for one day but for six weeks ; i.e., if 
the whole plant was pollen there would 
be still only one part of pollen to fifteen 
or twenty billion parts of air. The rose 
and the goldenrod are in even smaller 
quantities. Strangways ' estimates showed 
that there was not more than one grain of 
pollen for every thirty respirations. He 
advanced the theory that, while pollen 
plays a part, it does not irritate mucous 
membrane nor produce vasomotor paresis 
by its direct influence, but that a proto- 
plasmic substance found in pollen and in 
the vegetable kingdom, acting as a fer- 
ment, causes the formation of a toxin 
which is the real exciting cause. 

There can be little doubt that the neu- 
rotic element has been present in many, 
if not most, cases of hay-fever, and evi- 

[43] 



HAY-FEVER 

denced by depression, general lowering of 
tone, or exhaustion of the nervous sys- 
tem. The neurosis need not be acquired; 
in fact, it is often hereditary, which will 
be discust later. 

Holmes believes the disease to be in 
great part a neurosis with other debili- 
tating conditions. The fact that the bet- 
ter educated classes are most prone to 
this affection indicates the influence of 
neurotic tendency as well as exhaustion of 
the nervous system or debility or depres- 
sion thereof. The premonitory symptoms 
of this affection, as ably shown by Sajous, 
show the neurotic elements. He well asks, 
"If the local irritant is the only cause, 
why does the respiratory tract, the por- 
tion of the body first and most exposed 
to its effects, not become immediately 
influenced ?" This author also shows a 
case following enteric fever, the debilita- 

[44] 



WHAT HAY-FEVER IS 

ting and exhaustive character of which is 
well known, one preceded by malarial 
fever and another by bronchitis, pertus- 
sis, and varicella. 

Of the various other theories advanced 
are the lithemic, the intestinal or gastric, 
due to lack of proper assimilation, and the 
uric acid diathesis. The views herein ad- 
vanced are not at all inconsistent with the 
idea that the diatheses exercise a predis- 
posing influence in producing the affec- 
tion, which influence is debilitating and 
devitalizing. 

The local theory alone is not conclusive 
nor satisfactory; viz., that the disease is 
due to chronic nasal catarrh, or a local 
lesion, upon which the exciting cause acts. 
There is no doubt that diseased areas are 
more sensitive to the irritant, and espe- 
cially so in cases of lowered vital energy 
and lessened normal resistance, general or 

[45] 



HAY-FEVER 

local; but a large number of cases show 
no local disease. 

In all of the theories respecting this af- 
fection there is more or less regard for 
the agency of pollen in provoking the 
paroxysms of the disease; but as every 
one is exposed to the irritant, in those af- 
fected the soil must be prepared for the 
seed, that is, before the deposition of the 
pollen or dust or exciting agent there 
must be a morbid condition preexisting, 
which can so far be characterized as to 
call it lowered vitality or general or local 
resistance, which springs from a variety 
of cause* 

3. Periodicity 

On the continent of Europe, where it 
is less frequent, and in England, hay- 
fever prevails in June and July, The in- 
itial attacks occur during May and June 
and seldom last longer than September. 

[46] 



WHAT HAY-FEVER IS 

In India the malady chiefly occurs in Feb- 
ruary. In Australia, in and around Ade- 
laide, where the disease prevails, it oc- 
curs chiefly in September during the time 
of the blossoming of the Cape weed. In 
his work on hay-fever, Beard essays to 
show how the autumnal form is peculiar 
to the United States. One cause seems to 
be the flowering of the Eoman wormweed 
and the pollen of corn about the middle of 
August, and another in the prevalence of 
the " dog-days.' ' A third reason lies in 
the fact that there is less atmospheric 
ozone and electricity at this period than 
at any other time of the year, and, again, 
the hottest days are frequently in the lat- 
ter part of June. Beard also attached 
importance to a variety of hay-fever in 
which the attacks came on in September. 
This distinction is probably due to the 
fact that while one person is liable to the 

[47] 



HAY-FEVEB 

action of one pollen, another may be af- 
fected by a totally different pollen, and 
tlie annual attacks come on when the at- 
mosphere is permeated by a special pol- 
len to which the victim is individually sus- 
ceptible. Many persons are susceptible 
to the action of more than one pollen. Pa- 
tients often suffer from rose-colds in 
early summer, and, again, in August, from 
the autumnal form of hay-fever. Of the 
198 cases collected by Beard the onset of 
the disease occurred — 

From May 1 to May 10, in 2 cases. 

it It "in it tt Q-| (C n (( 

" June 1 " Juneio', " 11 _" 

tt tt iq tt tt OQ a o tt" 

" July 1 " July lo] " 6 " 
« 10 u « go, " 6 " 

ti cc on <c " qi (i 7 (( 

" Aug. 1 " Aug. loi " 7 " 

it u 1Q tt tt 2 0, « gl „ 

a u 20 " " 31, " 54 « 
" Sept. 1 " Sept 10, " 7 " 
" " 10 " " 20, " lease. 

« u 2 Q tt tt g 0> u 2casegt 

[48] 



WHAT HAY-FEVER IS 

Of Bosworth's eighty cases the greatest 
number, fifty-one, occurred between Au- 
gust 10th and August 27th. The usual 
date assigned for the commencement of 
paroxysms of hay-fever is the 29th of 
August. This form of the disease, com- 
mencing in the latter part of August, is 
designated as autumnal catarrh. 

Many patients have asserted that they 
are attacked annually on exactly the same 
date, and even the same time of day, each 
year. There can be little doubt that the 
psychic influence or peculiar mental an- 
ticipation may have a great deal to do 
with this circumstance. An attack may 
be brought on by the influence of the im- 
agination. Phoebus gives the history of 
a case in which attacks of sneezing were 
brought on "while looking at a beautiful 
picture of a hay-field." The well-known 
instance of J. N. Mackenzie, in which an 

[49] 



HAY-FEVER 

attack of hay-fever was brought on in a 
susceptible individual subject to rose-cold 
by means of an artificial rose may be 
explained on this ground. Bosworth con- 
siders that the time of occurrence is 
influenced by psychic causes, and is an- 
alogous to the recurrence of chills in 
intermittent fever, and considers that 
deception as to the actual time of occur- 
rence might be proved in hay-fever as in 
intermittent fever, in which changing the 
hands of the clock may lead to a change 
in the regular recurrence of the chills. 
Prince gives the history of a case in which 
a hay-fever subject under the influence of 
auto-suggestion, by means of writing fre- 
quently on paper and thinking, day and 
night, in leisure moments, and of slight 
hypnotism, prevented the premonitory 
symptoms of hay-fever, and she was free 
from the annual attacks for several years, 

[50] 



WHAT HAY-FEVER IS 

when they recurred and continued yearly 
thereafter. Prince asks, may it not be 
that the reason why certain places, such 
as Dublin, for instance, are reputed to 
have a specific influence against attacks, 
is the counter-suggestion thereby given 
that the patient will be free from attacks 
at such places? 

Pirrie states that it is next to impos- 
sible to definitely decide the duration of 
hay-fever attacks, as seasons, age, tem- 
perament, locality, treatment, and other 
circumstances tend to cause variations in 
different years and in different individ- 
uals. Treatment will do much to curtail 
the duration of the more prominent and 
distressing symptoms, but if left to them- 
selves it is seldom they depart under 
three or four weeks. A writer in the 
"Twentieth Century Practice of Medi- 
cine' ' estimates the duration as from four 

[51] 



HAY-FEVER 

to six weeks, according to the patient's 
surroundings and the atmospheric condi- 
tions. Asthmatic attacks may last from 
a few hours to three days and disappear 
suddenly. Morell Mackenzie states that 
attacks last from a few hours to several 
days, or even longer, finally ceasing al- 
most as suddenly as they came, and leav- 
ing no trace either in local lesions or in 
systemic disturbance. Bosworth gives 
eighty cases, showing the durations of the 
annual attacks as follows: 

From May 1 to frost 1 case. 

" May 25, to July 1 3 cases. 

" Aug. 1 1 case. 

" July 1 2 cases. 

" " 14 lease. 

" frost 5 cases. 

" July 4 4 " 

" " 26 5 " 

" Sept. 1 1 case. 

" Aug. 1 1 " 

" Sept. 1 1 " 

" frost 4 cases. 

" Aug. 27, to frost 51 " 

[52] 



a a 


15 


u u 


10 


" June 


1 


a u 


1 


tt u 


1 


t< (C 


10 


(( (( 


10 


" July 


1 


it ti 


10 


tt tt 


10 


it tt 


25 


" Aug. 


10 



WHAT HAY-FEVER IS 

All forms of hay-fever terminate with 
the first frost, and the long interval in 
which one may suffer is shown by the first 
case above from May 1st to cold weather. 
In the United States some who are at- 
tacked in May recover by the 1st of 
July; some attacked in July are well by 
the 15th of August ; some attacked in Au- 
gust recover by November 1st, while some 
unfortunates suffer throughout the period 
from May to November. The June type 
may be followed by a September visita- 
tion or become a permanent August at- 
tack, or the August type may disappear 
in certain individuals and reappear as a 

June cold. 

4. Symptoms 

Altho the affection is called hay- 
fever, there is seldom any degree of py- 
rexia, and, as a fever, it is not a decided 
one. There are two well-known types of 

53 ] 



HAY-FEVER 

the disease, — the catarrhal and the asth- 
matic. The onset of an attack is occa- 
sionally marked by feelings of general 
malaise, a loss of appetite, and depression 
of spirits. Indeed, these symptoms more 
or less characterize the entire course of 
the attack. A "tickling in the roof of the 
mouth' ' one week before the onset was 
felt by a patient of Sajous. Another 
speaks of dull pains in the head and back 
two weeks before; chills and shuddering 
ten days before the attack is experienced 
by another, while a large proportion com- 
plain of palpebral pruritis from two to 
ten days before the onset of the nasal 
symptoms. It is only in those subjects 
whose hay-fever is of some years' stand- 
ing, Sajous points out, that the premoni- 
tory symptoms are present, and gives in 
evidence the testimony of a fellow-physi- 
cian, viz.: "My attacks for some years 

[54] 



WHAT HAY-FEVER IS 

past came with much regularity, about 
August 12th to August 14th. On these 
dates this year I arranged to be on the 
water, on Lake Ontario and the St. Law- 
rence River, and entirely escaped every- 
thing like sneezing and irritation of the 
nose and eyes. Still I had the usual hot 
and slightly irritable skin, then an erup- 
tion of urticaria, accompanied by dis- 
ordered stomach. This experience is pre- 
cisely the same as in 1880, except that 
then I was on the Atlantic." Macdonald, 
in 1893, had a patient whose earliest 
symptoms were a curious coldness and 
pallor of the nose even in warm weather. 
In this connection it may be observed that 
in 1870 Roberts conceived the "pathog- 
nomonic symptom" to be coldness of the 
tip of the nose. 

Beard divided the symptoms into local 
and constitutional. Among the latter he 

[55] 



HAY-FEVER 

regarded fever, loss of strength, the al- 
tered appetite and the nervous system, 
considering under this last, depression, 
indisposition to labor, sense of fulness and 
heaviness of the head, pain in the fore- 
head and behind the ears, partial deaf- 
ness, restlessness at night, inability to 
sleep, a sense of suffocation, and general 
irritability. For the local phenomena, he 
looked upon the skin, in the heart, chest, 
mouth and nose, eyes and ears. 

The periodicity of the attacks is a prom- 
inent symptom and is difficult to explain. 
Some peculiar psychic influence occasion- 
ally acts to precipitate an exacerbation. 
In no other way can we explain the cases 
of John N. Mackenzie and Morell Mac- 
kenzie already cited. Analogous to this 
remarkable periodicity are those cases of 
intermittent fever wherein each alternate 
day, at a given hour, the chill occurs. This 

[56] 



WHAT HAY-FEVER IS 

is generally true, moreover, not only of 
ourselves, but of the world around us. As 
Holmes has beautifully shown in this con- 
nection, health and disease afford abun- 
dant illustration: The fixation of the 
number of heart-beats, of the respiratory 
movements, of the cycle of menstruation, 
or of the period of gestation are all recog- 
nizable in their unfailing occurrence, but 
their determination thereof, then, rather 
than at some other period, can not be ex- 
plained. So, in disease, are the muta- 
tions of the enteric temperature, the re- 
currence of the hectic, of the regularity 
of the return of the type of ague upon the 
second, third, or fourth days, or of hay- 
fever upon its annual date. We must 
recognize these phenomena as fixt, fur- 
ther we can not go. "As the rhythm of 
physiologic effects is under the control 
of the central nerve ganglia, and as inter- 

[57] 



HAY-FEVER 

mittency is a peculiarly marked feature 
of so-called nervous disorders, so far the 
annual return and the variations are 
evidences of the neurotic origin of hay- 
fever.' 9 

The onset of an attack of hay-fever be- 
gins with a sense of irritation referred 
to the upper nasal chambers, a sense of 
fulness or tightness across the bridge of 
the nose. There is an itching or burning 
sensation of the inner canthus of one or 
both eyes, which may be accompanied by 
convulsive movements of the eyelid, an 
itching or tingling in the roof of the 
mouth. Spasmodic sneezing soon occurs, 
and pain in the eyeballs and in the fron- 
tal regions develops. The paroxysms are 
more or less violent and prolonged. Ar- 
nold tells of sneezing in a patient for 
twenty-five times in close succession, forc- 
ing the pulse at the height of the attack 

[58] 



WHAT HAY-FEVER IS 

to one hundred and twenty beats to the 
minute. These paroxysms are followed 
by an abundant, thin, serous discharge 
from the nose. The mucous membrane 
of the nasal fossas swells so as to block 
up the nasal passages, and respiration 
through the nares becomes impossible. 
The escape of serum from the nostrils 
seems to increase the intense irritation 
and makes the sneezing worse. The dis- 
charge from both eyes and nose gradually 
grows thicker and may become semipuru- 
lent. There is often a certain amount of 
painful vision, and sometimes swelling, 
besides the usual pricking and stinging of 
the conjunctival surfaces. There are fre- 
quent transient paroxysms of lacrimation, 
and there is often much swelling of the 
eyelids as well as of the conjunctiva. The 
face becomes puffy and edematous, and 
the senses of taste and smell become im- 

[59] 



HAY-FEVER 

paired. The pharynx, mouth, and tonsils 
share in the engorgement and become red, 
and simultaneously the inflammation of 
the eyes, nose, and throat becomes intense 
and painful. Swallowing may become so 
difficult that there is little rest night or 
day. Insomnia is common and is often 
attended by nervousness and a sense of 
suffocation out of all proportion to the 
gravity of the condition. Cough is not a 
constant feature, but in a considerable 
proportion of cases it comes on in the sec- 
ond week, and lasts through the attack. 
Generally it is spasmodic and so incessant 
at night that sleep is impossible, and there 
are soreness and pain resulting from the 
straining of the diaphragm and intercos- 
tal muscles. Bronchitis does not usually 
result, and expectoration is absent or 
scanty until late. Cough may continue 
after all other symptoms have ceased. 

[60] 



WHAT HAY-FEVER IS 

The pulse and temperature are not gen- 
erally altered, but later in the attack the 
temperature may be raised two or three 
degrees, doubtless from disturbed rest. 
A " sufferer" records that, in some, the 
genito-urinary and rectal passages give 
the first warning by intense itching and 
burning. In one instance, a more than 
generally severe paroxysm induced rup- 
ture of the capillaries in the lacrimal ca- 
runcle of the right eye, causing engorge- 
ment of the organ and displacement of 
the visual axis, with consequent double 
vision for some days. The direct and re- 
flex changes in the vocal apparatus vary 
from loss of timber and harshness to 
complete inability to utter nasal vowels 
and consonants. 

The disorder varies much in intensity 
even in the same person within short in- 
tervals of time, so as to almost give 

[61] 



HAY-FEVER 

an intermittent character to the com- 
plaint. 

The attack finally ceases almost as sud- 
denly as it came on, leaving no trace of 
local lesion or systemic disturbance. It is 
accompanied in some patients with nettle- 
rash. Asthma is a late symptom, coming 
on after the acute symptoms have abated, 
and cough has existed for some time. It 
may appear at the height of the attack. 
It is more common in autumnal catarrh 
than in the early forms. Its period, as a 
rule, begins at the fourth week, and it 
does not vary from ordinary asthma. It 
is sometimes periodic, occurring at the 
same hour night after night. Paroxysms 
appear associated with antecedent bron- 
chial rather than nasal symptoms. Nasal 
reflex phenomena, without cough, may oc- 
casion paroxysms. Persistent cough more 
usually exists in the intervals between 

[62] 



WHAT HAY-FEVER IS 

paroxysms. Beard says that four-fifths 
of the sufferers have cough or asthma. 
The symptoms are not usually of equal 
severity each year. Asthma generally 
comes on in the daytime, a little ropy mu- 
cus being expectorated, and later an abun- 
dant frothy secretion. There may be only 
a slight remission, the dyspnea continu- 
ing so long as exposure continues. The 
attacks rarely produce emphysema of the 
lung, and sooner or later recovery ensues. 
Bosworth estimates that the asthmatic at- 
tacks come on earlier each year in those 
who have suffered from hay-fever in con- 
nection with asthma, and he believes that 
an attack of hay-fever is especially liable 
to develop an attack of bronchial asthma 
as a natural consequence of the disturb- 
ance in the nasal chambers. He also 
observed a number of cases in which hay- 
fever symptoms gradually abated while 

[63] 



HAY-FEVER 

the asthma became a prominent factor, 
and, again, that victims of hay-asthma 
finally acquired the perennial form of the 
disease, — the attacks occurring at all 
seasons without reference to the presence 
of pollen in the air. 

As already evidenced in Sajous' case, 
in a number of cases the attacks are pre- 
ceded by cutaneous eruptions. Laflaive 
cites cases with urticaria and eczema pre- 
ceding the onset of hay-fever. Facial pru- 
ritis and herpetiform eruptions are oc- 
casionally seen. J. N. Mackenzie speaks 
of an inflammation of the external audi- 
tory meatus in all respects analogous to 
that of the nose in hay-fever, occurring 
repeatedly in a lady during the summer 
months. 

Besides asthma, already mentioned, 
there is little tendency to permanent ill- 
effects except thickening of the nasal mu- 

[ 64] 



WHAT HAY-FEVER IS 

cons membrane from the prolonged irri- 
tation. Taste and smell may be impaired 
during and for a long time after the at- 
tack. General irritability and nervous- 
ness may be more or less persistent. El- 
derly sufferers for a long time may have 
weakened hearts which intermit during 
attacks, which may recover with return- 
ing health or result in cardiac dilatation. 
Wyman mentions pneumonia in three 
cases during attacks. In one case the ca- 
tarrh ceased for two weeks to return after 
the pneumonia disappeared, when asthma 
also came on for the first time. 

5. Its Pathology, Diagnosis aet> 
Prognosis 

Morell Mackenzie states that hay-fever, 
leaving no permanent structural lesion be- 
hind it, can not, therefore, be strictly said 
to have any pathology. Surely it is that 

[65] 



HAY-FEVER 

no distinct specific organisms have been 
found. Sajous calls attention to the dis- 
tinct physiologic functions of the two re- 
gions of the nasal cavities, the olfactory 
and the respiratory. The filaments of the 
olfactory nerve cover the superior tur- 
binated bones, and the upper third of the 
middle turbinated bones, and the corre- 
sponding portion of the septum. Thus 
the upper portions of the nasal cavities 
are devoted to the sense of smell and do 
not enter into the pathology of hay-fever. 
The respiratory portion of the nose in- 
cludes all the surfaces below the olfac- 
tory. It is under the control of the vaso- 
motor nerves of the sympathetic system, 
and is quite sensitive to local or periph- 
eral irritation. This sensitiveness resides 
in the terminal filaments of the sen- 
sory nerves, distributed over the surfaces 
of the mucous membranes. The mem- 

[66] 



WHAT HAY-FEVER IS 

branes of the posterior areas of the nasal 
fossae are supplied with several branches 
of the sphenopalatine ganglion, which en- 
ter by the sphenopalatine foramen. This 
ganglion possesses a sympathetic root de- 
rived from the carotid plexus through the 
vidian nerve, thus establishing a connect- 
ing link between the nasal mucous mem- 
brane and the sympathetic system. 

In health the nasal mucous membrane 
pours out from twelve to sixteen ounces 
of watery serum daily, which — that it may 
warm, moisten, and cleanse the inspired 
air on its passage to the lungs — is dif- 
fused over the convex surfaces of the tur- 
binated bones. The centers in the medulla, 
through the vasomotor, control and regu- 
late this process of serous exudation; the 
nicety of which regulation is seen in the 
adjustment thereof to the varying hygro- 
scopic and thermic conditions of the air. 

[67] 



HAY-FEVEB 

The experiments of John N. Mackenzie* 
in 1884, showed: 

1. That in the nose there exists a well- 
defined sensitive area whose stimulation, 
through a local pathologic process or 
through an extra irritation, is capable of 
producing an excitation which finds its 
expression in a reflex act, or in a series of 
reflected phenomena. 

2. That this sensitive area corresponds, 
in all probability, with that portion of the 
nasal mucous membrane covering the tur- 
binated corpora cavernosa and the most 
sensitive spots covering the posterior end 
of the inferior turbinated body and the 
septum immediately opposite. 

3. That nasal cough is caused only by 
stimulation of this area. 

4. That the tendency to evolution of 
reflex phenomena varies in different indi- 
viduals, and is probably dependent upon 

[68] 



WHAT HAT-FEVER IS 

the varying degree of excitability of the 
erectile tissue. 

These sensitive areas correspond to 
the distribution of the sphenopalatine 
branches of the superior maxillary nerve, 
as distinguished from the nasal branch of 
the ophthalmic, which latter supplies the 
more anterior portions of the nasal fos- 
sae. The former nerves, derived through 
the ganglion of Meckel, therefore, prob- 
ably contain the vasomotor nerves which 
govern the erection of the turbinated 
tissue, and, hence, the localization of 
the sensitive areas becomes the key to the 
mechanism of the paroxysms. Neverthe- 
less, Beard was inclined to transfer 
the point of greatest excitability from the 
peripheral ends of the nerve-filaments to 
the nerve-centers themselves, because it 
seems a more comprehensive explanation 
of the varied phases of the disease. 

[69] 



HAY-FEVER 

Roe explained that the more frequent 
occurrence of asthmatic paroxysms at 
night might be brought about by the 
gravitation of blood to, or the contact of 
polypi upon, these sensitive areas. Sajous 
thought it was evident that there were 
three areas capable of producing reflex 
symptoms in the course of a paroxysm of 
hay-fever, and that the three combined 
formed the key to the local nervous ele- 
ment, not that the three areas must take 
part, but in some, one of them, in others, 
two of them, etc. In the asthmatic cases, 
he noticed that both anterior and pos- 
terior areas were sensitive, the latter 
.especially so. 

Capp pointed out two distinct spots or 
areas of the mucous membrane of the 
nasal cavities, one at the posterior and 
one at the anterior extremity of the in- 
ferior turbinates, one or both of which 

[70] 



WHAT HAY-FEVER IS 

may be supersensitive in individual cases ; 
also a spot in the anterior nasal chambers 
at the upper angle formed by the septum. 
All these are exquisitely sensitive, and, 
when irritated, produce extensive reflex 
symptoms. Trouble appears to begin at 
one or all of the points, while the rest of 
the Schneiderian membrane is in normal 
condition; but with sneezing, hyperemia 
and hyperesthesia ensue, and, through 
continuity, may extend to throat, ears, 
and eyes. 

In speaking of the three reflex areas, 
Holmes said that it is regarded that all 
points of the cavernous tissue are not 
equally susceptible to irritation; the sen- 
sitive areas are the inferior turbinates 
(the posterior and middle reflex areas) 
and the portion of the septum immedi- 
ately opposite, being particularly related 
to cough and asthma; the anterior, in the 

[71] 



HAY-FEVER 

vestibule, to sneezing, lacrimation, and 
other catarrhal symptoms. "We might 
compare these reflexes with certain other 
cases of reflex asthma (not hay-fever) 
benefited by removal of the tonsils. 

Bosworth regarded the continuous 
sneezing as pathognomonic and holds that 
the hyperemia is " confined entirely to the 
large venous sinuses, the capillaries 
proper not being congested," and speaks 
of the watery, serous discharge with the 
bluish-gray " tinge of the mucosa verging 
on opalescence, the surface of the mem- 
brane being covered with slightly viscid, 
watery serum, which gives it a glassy, 
semitranslucent aspect." 

During an attack of hay-fever the erec- 
tile tissues of the nasal passages and the 
posterior throat become distended, the 
blood-vessels are engorged, groups of 
lymph-cells fill the lymphatic spaces, the 

[72] 



WHAT HAY-FEVER IS 

mucous surface is crowded with migrat- 
ing leucocytes (white blood-corpuscles), 
younger epithelial cells are vacuolating 
and proliferating, secretion is increased 
in quantity and altered in character and 
composition, sensation is heightened, in- 
tensified, altered, or benumbed, and the 
whole metabolism of the affected region 
is profoundly disordered. Examination of 
the lower borders of the turbinated bones 
will disclose the mucous membranes of 
the nasal cavities arranged in thick, loose 
folds, owing to the peculiar distribution 
of the network of arteries and veins which 
go to make up "cavernous tissue/ ' It is 
peculiar to this tissue that it may suddenly 
be engorged with blood, extremely dis- 
tending it, and as suddenly emptied and 
the engorgement relieved. It is especially 
thick over the inferior turbinated bones 
and over the lower and posterior part of 

[73] 



HAY-FEVER 

the nasal septum, and also upon the lower 
edge of the middle turbinated bone. In 
acute conditions the engorgement and dis- 
tention soon subside. In chronic states the 
mucous membrane becomes markedly thick- 
ened and the blood-vessels enlarged and 
tortuous. The subsidence of the engorge- 
ment can not occur, and as a result there 
is a greater or less degree of closure of the 
nasal passages. 

The mucous membrane of the nasal cav- 
ities in hay-fever does not present the 
characteristic features of an acute inflam- 
mation. The impact of pollen or exciting 
irritant causes complete relaxation of the 
large veins of the turbinated bodies and 
an exudation of serum, which relaxation 
continues so long as pollen or the irritant 
is in situ, but as soon as it is removed the 
normal caliber is again restored and the 
attack subsides. Deviations of the sep- 

[74] 



WHAT HAY-FEVER IS 

turn or chronic rhinitis are occasionally 
found concurrent with the disease, but 
can not be regarded as characteristic. 

Hay-fever may be distinguished from 
asthma, common catarrh, bronchitis, acute 
rhinitis, remittent fever, and catarrhal 
conjunctivitis. The salient feature of 
hay-fever is its periodicity or annual re- 
currence. This is part of its very nature, 
is the central point of diagnosis, is its 
chief characteristic, and to its elucida- 
tion, Holmes says, all existing theories 
tend. 

Beard states that hay-fever is like 
asthma in the following points : 

1. It is hereditary; 

2. It is more or less periodic; 

3. It is paroxysmal; 

4. It is correlated to other functional 
nervous affections; 

5. The paroxysms are excited by a great 

[75] 



HAY-FEVER 

variety of irritants ; persons being differ- 
ently affected; 

6. It is singularly obstinate and is re- 
lieved by the same remedies. 

Bosworth considers hay-fever depen- 
dent upon: 

1. A neurotic habit; 

2. Pollen in the atmosphere; 

3. A disordered condition of the nasal 
passages. 

While asthma is dependent upon : 

1. A general neurotic condition; 

2. Obscure conditions of the atmos- 
phere; 

3. Diseased bronchial (not nasal) mu- 
cous membranes. 

It is the comparative suddenness of the 
onset, as well as its sudden departure, the 
violent paroxysms of sneezing, and the 
character of the nasal discharges which 
are the peculiar features of hay-fever. 

[76] 



WHAT HAY-FEVER IS 

The first attacks are likely to be mistaken 
for ordinary coryza, but here the abrupt 
onset, the characteristic edematous puf- 
finess of the eyelids, the absence of con- 
stitutional symptoms will indicate the 
difference. In children, moreover, at- 
tacks of hay-fever are most liable to be 
mistaken for acute colds or rhinitis, — but 
here, again, the above points may serve to 
distinguish, together with the sequence of 
the symptoms, the time of year, and the 
physical signs of an acute bronchitis, if 
it extends so far. The approach of cold 
weather and the coincident departure of 
the symptoms will make clear a diagno- 
sis, wliile the history of previous attacks 
at the season of the year most favorable 
to hay-fever, the presence of certain irri- 
tants, and the general condition of the 
bodily symptoms may be of aid in dis- 
tinguishing the affection. In acute rhi- 

[77] 



HAY-FEVER 

iritis there are several stages, viz.: First, 
a dry stage, lasting for a few, say twelve, 
hours; second, a serous discharge lasting 
two or three days; and, third, a muco- 
purulent discharge for from three to five 
days, — while the entire attack runs its 
course in from five to ten days if no com- 
plications ensue. In hay-fever there is 
no dry stage ; the discharge from the out- 
set is purely serous and never muco- 
purulent during the entire course. The 
nasal discharge in hay-fever is sometimes 
slightly opaque, and it may contain some 
few epithelial cells and viscid mucus. In 
acute rhinitis examination of the nares 
will show an inflammatory area while hay- 
fever shows none. Hay-fever is a vaso- 
motor paresis, and is easily diagnosed 
from inflammatory coryza by the swollen 
bluish-gray appearance of the inferior 
turbinated bones, and by the fact that the 

[78] 



WHAT HAY-FEVER IS 

first train of symptoms continues through 
to the end* Examination of the nares will 
disclose occlusion due to the swollen tur- 
binated bones lying in contact with the 
septum. The appearance of the mucous 
membrane itself is characteristic and only 
slightly resembles an inflammatory pro- 
cess. It is markedly swollen, not bright 
red as in rhinitis, but bluish-gray, cov- 
ered with a thin, slightly viscid, watery 
serum, giving it a glassy, semitranslu- 
cent, at times opalescent appearance. 
Again, the marked pufliness of the eye- 
lids, the great suffusion of the eyes, the 
photophobia, and even epiphora are dis- 
tinguishing features of hay-fever. 

The sensitive areas spoken of, particu- 
larly those on the lower and posterior 
parts of the septum and the inferior tur- 
binated bones, are of value in differen- 
tiating hay-fever, and the markedly pro- 

[79] 



HAY-FEVER 

nounced paroxysms of sneezing are very 
prominent in hay-fever. 

People are subject in the changeable 
climate of spring and early summer to 
catch colds, and especially is this true of 
those prone to catarrh. These cases are 
sometimes mistaken for hay-fever. The 
readiness, however, with which they yield 
to anti-catarrhal treatment shows their 
nature. 

The prognosis is invariably good as to 
life. Sufferers often live to advanced 
ages. Hay-fever is no bar to life-insur- 
ance, but unless rationally treated the 
chances of permanent cure are very small. 
There are few exceptions to the rule that 
the tendency is, when once established, to 
an annual recurrence, unless the predis- 
posing causes are removed, or there is 
removal of or away from the exciting 
cause. Beard states that hay-fever has 

[80] 



WHAT HAY-FEVER IS 

no effect on longevity, and that, judging 
from observation and analogy, this afflic- 
tion may act as a kind of safety-valve for 
the nervous diathesis, preventing other 
and more serious disorders, and thus be- 
coming the friend rather than the enemy 
of life. When once attacked, unless 
properly treated, escape is rare in any 
subsequent year. Even changes in consti- 
tution in extreme age are no bar or pro- 
tection. It rarely skips a year, provided 
locality and influence are the same. Ab- 
solute immunity is only obtainable at the 
price of temporary exile. There is no 
proof that hay-fever is generally milder 
or severer in certain years all over the 
world or over a country, yet evidence is 
satisfactory that in certain localities it 
varies greatly in different years. 

Now and then, but not often, the ten- 
dency to the disease seems to be out- 

[811 



HAY-FEVER 

grown. In one of Beard 's cases the dis- 
ease skipped two years. Dr. Gibbons, of 
California, mentions a terrible case in 
which the attacks in successive years be- 
came lighter and lighter and finally dis- 
appeared entirely. 

With respect to increase or decrease 
of severity of symptoms with advancing 
years there is no constant law. In some 
cases the disease grows milder, in others 
severer, in others still, years of compara- 
tive mildness alternate with years of com- 
parative severity. The early form may 
change into the later form. There is no 
donbt, however, that attacks may change 
from the early to the late form, and vice 
versa, and in advancing years may be 
milder. Bosworth states that the younger 
the patient the better is the promise of 
relief; and that rose-cold, belonging more 
especially to early life, is to be regarded 

[82] 



WHAT HAY-FEVER IS 

more favorably than other forms. Mac- 
donald has observed spontaneous disap- 
pearance in children, perhaps due to an 
increase, pari passu with growth and de- 
velopment of nervons stability. 

As regards the termination of each in- 
dividual attack the prognosis is invari- 
ably favorable; cessante causa, cessat 
effectus. There is almost equal certainty 
that with the same causative influences 
the attacks will reappear upon exposure 
to ^e exciting cause. It is peculiar, too, 
that the disease of one year's standing 
has proved as obstinate as one of from 
twenty to thirty years' duration. In 
these instances it may be a question as to 
how firmly fixt has become the neurotic 
habit. 

W. W. Bulette, of Colorado, in 1896, as 
a result of his own experience, made the 
assertion that more than eighty per cent. 

[83] 



HAY-FEVER 

of hay-fever sufferers can be permanently 
and effectually cured. Thoro examina- 
tion of the patient and elimination of 
every possible source of irritation and 
pathologic condition are necessary. 

I desire to be more emphatic, and from 
my results in the treatment of over 200 
cases during the last twenty years, I be- 
lieve that the curability of the disease 
can not be questioned. That all cases can 
be cured is questionable; but we can un- 
hesitatingly say that a majority of cases 
are curable, and that positive relief, with- 
out change of residence or inconvenience, 
can be afforded during the period of oc- 
currence, if treatment is directed along 
the lines laid down in the following 
chapter. 



[84] 



PART II 
ACCEPTED CAUSES 



[86] 



PART II 

ACCEPTED CAUSES 

1. When Due to Some Exciting Agent 
Such as Pollen 

It being generally recognized that there 
are two elements entering into the causa- 
tion of hay-fever, viz., an exciting agent 
and a predisposing or preexisting con- 
dition, regard will be given the subject 
of causation from this standpoint. 

A great number of agencies have been 
regarded as the direct causes of this 
disease, but opinion in the main has as- 
signed pollen as the essential factor, act- 
ing upon the preexisting condition or 
predisposition. It may be better, however, 
to give a resume of other agencies before 

[87] 



HAY-FEVER 

regarding this subject of pollen. The 
most important of these are heat, light, 
dust, ozone, overexertion, ipecac, lyco- 
podium, coumarin, benzoic acid, choco- 
late, or several of these in combination. 

No attempt to signify or designate a 
definite cause was made by the early 
writers until 1819, when Bostock first 
described the malady and ventured the 
view that it was due to the influence of 
solar heat. He attributed his own pro- 
longed sufferings to the exposure to the 
sun's rays and fatigue. 

Some time after, Phoebus attributed the 
affection to "the first heat of summer," 
which, he stated, "is a stronger cause 
than all the grass emanations put to- 
gether." Phcebus subsequently modified 
his views so as to regard the first heat of 
summer as acting only in an indirect man- 
ner as an exciting cause, and admitted 
[88] 



ACCEPTED CAUSES 

that hay and the blossoms of rye caused 
exacerbations. It can not be contended, 
at this day, that heat alone will provoke 
the disease. In the plains of India when 
the heat is greatest it is not found, al- 
tho later in the year, in the cooler 
months and before vegetation is burned 
up, it does appear; but among the hills 
of India, where the climate is milder and 
the grasses and cereals are in blossom, 
hay-fever exists. At sea, when vessels 
are becalmed and heat is most intense, and 
in the great heat of the desert hay-fever 
is not found. Pirrie shows that great 
heat is common to all cases, even when 
the vegetable world is looked to for the 
cause, and strangely points out that the 
premonitory feelings of an attack coin- 
cide with those caused by high tempera- 
ture. One of the most interesting cases 
from this standpoint is that of an En- 

[89] 



HAY-FEVER 

glishman, who, altho not a medical 
man, was well known to science — Bichard 
Proctor. The asthma — for it took this 
form — occurred only during the cold 
months, and was always aggravated by a 
rime or hoar-frost, especially if the lat- 
ter was followed by a bright, sunny day. 
It is a striking fact that in regions com- 
paratively free from the disease persons 
subject to it become worse on warm days, 
or when the wind blows from the south. 
It has been found by experience that 
while this aggravation by winds is in 
most part due to the presence of more 
pollen, the higher temperature is also in 
a measure responsible. Hot, dry days are 
more favorable to the dissemination of 
pollen than rainy ones, and it becomes 
especially active when hot, dry periods 
follow stormy weather. In the light of 
Blackley's experiments upon the amount 

[90] 



ACCEPTED CAUSES 

of pollen in the atmosphere, these facts 
would seem to explain the action of heat 
and sunlight as an active cause in the pro- 
duction of the exacerbations of hay-fever. 
Phoebus was dissatisfied with the view 
of the influence of solar heat, and thought 
that the longer days, which produce a 
more continuous action of light, were per- 
haps to blame; but where light is strong- 
est and lasts the longest — indeed, in the 
land of the "midnight sun" — hay-fever 
is practically unknown. Pirrie called at- 
tention to the fact that exposure to strong 
light aggravated the symptoms of the 
attack. The cited case of the late Eichard 
Proctor is an example of the truth of this. 
There is an instance of the widow of a 
clergyman whose attacks, most severe in 
summer, were aroused by sunlight in the 
early morning. Ingals knew a clergy- 
man who was unable to cross the street 

[91] 



HAY-FEVER 

on a hot day without sneezing violently 
unless he carried an umbrella. Persons 
with sensitive mucous membranes, espe- 
cially subjects of hay-fever, are, no doubt, 
sometimes liable to attacks of sneezing 
from sunlight; but these symptoms must 
not be mistaken for true hay-fever. In- 
gals states that he knew an individual in 
whom attacks of sneezing were brought 
on by exposure to bright gaslight. Gas- 
light was also regarded by Beard as a 
cause of this affection. However, Morell 
Mackenzie shows that gaslight is em- 
ployed more in winter when the affection 
does not prevail than in the English 
spring and American autumn, when the 
affection most prevails. Nothing can ex- 
ceed the reflected glare of sunlight at sea 
on a bright day, yet it is upon the sea 
that exemption from attacks of hay- 
fever is universally found. 

[92] 



ACCEPTED CAUSES 

From his scientific investigations upon 
the subject, Beard, whose published work 
is a model, concluded that it was ex- 
tremely probable that dust occasionally 
caused hay-fever. Out of 198 cases of 
hay-fever reported by him no less than 
104 attributed the affection to dust. One 
hundred and forty-two of these cases, how- 
ever, occurred between May and Septem- 
ber, the usual hay-fever season; and the 
lay, not the trained professional, mind 
advanced the causes. Some attributed the 
affection to "indoor dust"; some to "cin- 
ders." These data of Beard, therefore, 
must be taken cum grano salis. More 
especially is this so since a paroxysm of 
sneezing and subsequent coryza, fre- 
quently brought on in normal health by 
the mechanical irritation of dust or even 
strong odors, should hardly be dignified 
as an attack of hay-fever. In England, 

[93] 



HAY-FEVER 

in February, March, and April, when 
strong east winds often blow clouds of 
dust against the face, the symptoms of 
hay-fever do not appear, whereas in June 
and July, when dust is comparatively lit- 
tle, the affliction is most extant. 

Holmes stated that even in winter-time 
stirring among old books or in an old 
garret the exposure to the fine dust there- 
from would, by simple mechanical irri- 
tation, produce an attack in him. It has 
been the consideration that dust, or pol- 
len, acting as any other form of dust, 
could be kept from entering the nasal 
chambers that has given rise to the va- 
rious inventions to purify the air before it 
enters the nose, such as plugs of cotton or 
wool, and veils (which, in addition, soften 
the glare of the sun and lessen the irritating 
action of winds. Every hay-fever sufferer 
knows the little value of such a device. 

[94] 



ACCEPTED CAUSES 

From the vast quantity of facts and ob- 
servations gathered together by him, 
Phoebus, who previously had ascribed sun- 
light as the cause of hay-fever, endeav- 
ored to extract a complete theory of the 
disease. He suggested an excess of ozone 
in the atmosphere as a possible cause. It 
remained, however, for Blackley, in 1873, 
by his great endeavors and scientific 
methods of investigation, to disclose the 
fallacy of this theory. He purposely 
breathed air highly charged with ozone 
for five or six hours without effect; and 
without inconvenience he inhaled ozone 
artificially prepared and in quantities 
far exceeding that found in the same vol- 
ume of atmospheric air. This same phy- 
sician also studied upon himself the ef- 
fects of benzoic acid, a substance shown 
by Vogel to be contained in Anthoxan- 
thum odoratum and Rolens odoratus, the 

[95] 



HAY-FEVER 

two species of flowering grasses to which 
the causation of hay-fever has been at- 
tributed. Likewise he investigated the 
odorous principle of many flowering 
grasses, coumarin, and the volatile oils 
which impart to many plants, such as 
peppermint, juniper, rosemary, and lav- 
ender, their characteristic perfume. In 
all these cases the results were negative. 
Various other exciting causes are in 
numberless variety and many of purely 
idiosyncratic nature. Emanations from 
dry hay, sunlight, gaslight, heat, minute 
organisms as supposed by Helmholtz, the 
"mange" insect, dusts of all kinds, bad 
air, railway smoke, brimstone matches, 
flowers and fruits, odors from dogs, cats, 
horses, cattle, rabbits, guinea-pigs, and 
wild animals, have all been held respon- 
sible for the paroxysms. Ward Smith 
records linseed meal and mustard as 

[96] 



ACCEPTED CAUSES 

exciting causes. Wm. Murrell mentions 
powdered May-apple (podophyllum), the 
effluvia of clean pocket handkerchiefs 
fresh from an ironing table, locust-tree 
blossoms, mulberry blossoms, and fruit. 
The exhalations from feathers have been 
regarded as causes. It is well-known that 
various drugs like ipecacuanha and lyco- 
podium give rise, to attacks, and sulfur 
has been mentioned as a cause. Sir 
Thomas Watson names a servant in St. 
Bartholomew's Hospital affected by ipe- 
cac. Cullen tells of an apothecary's wife 
who, whenever ipecac was triturated in 
the shop, had an attack of hay-fever. He 
also mentions the vicinity of a rice- 
threshing floor as a provocative cause. 
Itzigson tells of a merchant who had hay- 
fever paroxysms whenever fresh coffee 
was handled in his presence ; and it is re- 
corded of a dyer that he could not work 

[97] 



HAY-FEVER 

when the wood of the oak (Quercus tine- 
toria) was lying about. The author 
knows of a case in a physician in whom 
violent paroxysms of sneezing are in- 
duced by the tasting of chocolate. It is 
related in the "Twentieth Century Prac- 
tise of Medicine" that a hay-fever pa- 
tient fond of tomatoes and watermelons 
was unable to eat of them during the 
usual hay-fever season without most vio- 
lent disturbance of the gastro-intestinal 
tract. Bastian was subject to attacks of 
an affection like hay-fever while dissect- 
ing the Ascaris megalocephala, a parasite 
infecting the horse. Hyde Salter tells of 
a clergyman affected by the vicinity to a 
dead hare, and who was thus able to de- 
tect the presence of a poacher. H. Charl- 
ton Bastian had like effects from the 
"mange" insect of the horse. Einger 
and Murrell tell of a young gentleman 

[98] 



ACCEPTED CAUSES 

made worse by the vicinity of horses or 
stable people. Once, while in the theater, 
an attack suddenly supervened without 
any appreciable reason until a horse gal- 
loped upon the stage. Macdonald, in 1893, 
mentioned a patient who, two or three 
hours after having patted his horse with 
his gloved hand, inadvertently put it to 
his face, and was immediately seized with 
a violent paroxysm. The odor from the 
inner aspects of the legs of the horse was 
very irritating to one writer, a "suf- 
ferer." Einger and Murrell cite the case 
of a gentleman who, subsequent to an 
acute pleurisy, was ever after a subject 
of "hair-caterpillar asthma," and was 
immediately attacked if by any chance he 
touched a caterpillar. 

The difficulty of sometimes finding 
some exciting agent is shown by the case 
of Drenger. After searching several 

[99] 



HAY-FEVEE 

years in vain for the cause of attacks of 
hay-fever caused by entry into a certain 
room in a house, and after ransacking 
nearly everything in the house, a mattress 
was suspected, and, upon removal, was 
satisfactorily shown to be the offending 
agent. 

The odor of peaches, of violets, of the 
mignonette, of chocolate, of musk, and of 
peppermint, has come in for a share of the 
blame. Trosseau relates of himself that 
attacks came on when he entered a room 
in which there were violets. The botanist 
Broussais was often impeded in his work 
by attacks caused apparently by the odor 
of a rose. Hunerswolff and Morell Mac- 
kenzie each cite a case in which the per- 
fume of the rose produced attacks of 
coryza. The former's account is in the 
"Ephemerides," and has been often re- 
ferred to. The latter 's case proved rebel- 

[100] 



ACCEPTED CAUSES 

lions to treatment, and the sufferer had, 
at last, to banish these flowers from her 
garden. That this peculiar antipathy to 
flowers is often imaginative is also shown 
by John N. Mackenzie, who cites the case 
of a subject of hay-fever to whom he 
handed an artificial rose. Immediately an 
attack of rose-cold ensued. A patient men- 
tioned by Phoebus and Morell Mackenzie, 
while gazing upon a picture of a hay field, 
was seized with an attack of hay-fever. 
These last two instances indicate the 
psychic influence rather than any extrane- 
ous cause, but they serve to show the 
varieties of exciting agents. 

The external cause which has been by 
far the most generally recognized and ac- 
cepted as the most frequent is pollen. The 
older writers upon this theory did not dis- 
tinguish the underlying condition neces- 
sary before pollen could act as a cause of 

[101] 



HAY-FEVER 

the disease. The remarkable and elabo- 
rate experiments of Blackley, from 1866 
to 1878, conclusively prove that a most 
important exciting cause of hay-fever is 
found in the action of pollen upon the 
mucous membrane of the nasal cavities. 
In his own person he showed that the in- 
halation of pollen always brought on the 
symptoms of hay-fever; that there was a 
direct relation between the intensity of 
the symptoms and the amount of pollen 
in the air, and that none of the other 
agents referred to, such as heat, light, 
ozone, dust, or odors, would, of themselves, 
cause the distress. His range of ob- 
servation included the pollens of various 
grasses and of cereals and of plants of 
thirty-five other natural orders. His ex- 
periments were made in the hay-fever sea- 
son in England, between the end of May 
and the latter part of July, and showed 

[102] 



ACCEPTED CAUSES 

that ninety-five per cent, of the pollen con- 
tained in the atmosphere belonged to the 
Graminacece. The apparatus from which 
he obtained the most satisfactory results 
in his investigations consisted of a verti- 
cal plate of glass, % of an inch in diam- 
eter. It was covered with a hood, and was 
pivoted to an upright staff. A weather- 
vane surmounted the hood to control the 
face of the glass-plate before the wind. 
Upon this glass-plate was affixt a micro- 
scopic cover-glass, one centimeter in di- 
ameter, covered with glycerin. Any pollen 
floating in the atmosphere would thus be 
carried upon the plate by the wind-current 
and adhere to the glycerin upon the glass- 
slide. Blackley thus found that the amount 
of pollen caught upon the plate increased 
progressively from the seventh to the thir- 
tieth of May, when twenty-five grains were 
counted, to seventy-six grains on the 

[103] 



HAY-FEVER 

eighth of June, and to 280 grains on the 
tenth of June. On the twenty-eighth of 
June 880 grains were counted, after which 
date they decreased until the first of Au- 
gust, when they had completely disap- 
peared. Bright, sunny days brought 
large quantities of pollen, while rainy days 
decreased the amount. Passing showers 
ameliorated the individual symptoms, tho 
not affecting the amount of pollen depos- 
ited upon the slide. Blackley also clearly 
showed that the mucous membranes of the 
nasal fossae were not affected by pollen in 
the atmosphere when twenty-five grains 
per diem only were deposited on his glass, 
while seventy-five grains in twenty-four 
hours would irritate in certain individuals. 
When 280 grains of pollen per day were 
deposited the direct action upon the mu- 
cous membrane of this quantity would 
result in complete vascular dilation. 

[104] 



ACCEPTED CAUSES 

Clinical observation has shown a paral- 
lel, but by no means a complete, analogy 
to the above phenomena in the action of 
cocain in different strengths of solution. 

Emanations from the rose and from rye 
have been shown to have caused coryza, 
occlusion of the nostrils, and sneezing for 
from six to eight hours. The sweet-scented 
vernal grass (Anthoxanthum odoratum), 
sweet-scented soft grass (Holcus odora- 
tus), meadow grass, meadow fox-tail, 
Indian corn, barley, wheat, oats, bean- 
flowers, lilies, elder trees in bloom, the 
goldenrod, hay, timothy, and clover, and 
others may be mentioned. In America the 
pollen of the Eoman wormwood, ragweed, 
or hogweed {Ambrosia art emisice folia), 
is the most commonly referred to. It is 
very common in nearly all the States. It 
blossoms in August and September, the 
prevalent time of hay-fever. Wyman and 

[105] 



HAY-FEVER 

his son, who had fled to the White Moun- 
tains to avoid hay-f ever, were immediately 
attacked when a package of the ragweed 
was opened there. The seashore, usually 
exempt, sometimes is not so, probably due 
to the presence there of the pollen of the 
Artemisia gallica, another kind of worm- 
wood. In England the Anthoxanthum odo- 
ratum, or "sweet-scented vernal grass,' ' 
seems especially causative. There must 
also be mentioned the common daisy 
(Bellis perennis) of England; also the 
rye-grass (Lolium perenne) and "sweet- 
scented soft grass" (Holcus odoratus). 
In Germany the rye-blossom is chiefly in- 
dicated as a cause. In Australia the Cape 
weed pollen is regarded as most com- 
monly provocative. It covers the hills 
round about Adelaide to the height of 
some thousand feet or so. Most of the 
population of Adelaide is affected with 

[106] 



ACCEPTED CAUSES 

hay-fever during the time of its blossom- 
ing, viz,, in September. In India, where 
the malady occurs chiefly in February, it 
is the blossoms of the mango-tree (Mangi- 
fera indica) that are held responsible. 

J. C. "Wilson holds that most subjects are 
not sensitive to emanations from hay, and 
points out that there are no distinctive 
bacteria to give rise to the affection. 
Marsh, himself a sufferer, stated his be- 
lief in the pollen theory, conceiving hay- 
fever analogous to Rhus toxicodendron, 
or ivy-poisoning of the skin. 

There are two authentic cases which 
would impair the pollen theory, the well- 
known exemption of hay-fever subjects at 
sea being granted. One is mentioned by 
Walshe, in which a passenger retained his 
symptoms of hay-fever during a passage 
across the Atlantic. Abbotts Smith has re- 
ported the other, in which the disease came 

[107] 



HAY-FEVER 

on at sea nine miles from land. In this lat- 
ter case, unfurling the sails in which a 
large quantity of pollen had been folded 
may explain the occurrence. In the former 
instance the diagnosis was by no means 
certain and the presence of some other ir- 
ritant may have accounted for the dis- 
tress. Moreover, it is by no means impos- 
sible for pollen to be deposited on a ship 
even when miles away from land. In 
speaking of the distribution of pollen Dar- 
win tells of how the ground near St. Louis, 
in Missouri, has been so widely covered 
with pollen that it looked as if it had been 
sprinkled with sulfur. Pine forests, 400 
miles south, were probably the place and 
distance from which it came. On March 
16, 1883, in Philadelphia, ignorant people 
took for brimstone a shower of yellow 
pollen which had been blown from some 
distant pine forest. 

[108] 



ACCEPTED CAUSES 

After citing many of the various causa- 
tive pollens Holmes says that he is "not 
aware that any specialized action has been 
proved; all act (if at all) by mechanical 
irritation." He also shows the punctu- 
ality of flowering on the selfsame date 
yearly is an absurdity, depending, as the 
flowers do, upon the variations of the 
seasons. 

The date of the flowering of plants 
varies within certain limits, and he points 
out the mutability of the blossoming date, 
or, more rationally, its limited variation, 
and further adds that "even as a mere ir- 
ritant, as pollen affects comparatively few, 
it must act upon a condition which is pre- 
existent, which is, therefore, independent 
of and predominates it, else would the 
cause, pollen, produce it universally." 

As already mentioned, it has been 
claimed, that a toxin generated from pol- 

[109] 



HAY-FEVEK 

len by a fermentative process in an alka- 
line solution is the cause of hay-fever. 

2. The Predisposing Causes 

While millions of people are exposed to 
the exciting causes of hay-fever, compara- 
tively few suffer from it, and that there is 
an underlying condition, predisposition, 
or idiosyncrasy, can hardly be doubted. 
Exactly what this is, or on what it depends, 
is unknown. Abbotts Smith, as early as 
1865, spoke of a predisposition to attacks 
of hay-fever as one of the principal causes 
thereof. As Holmes has shown, there must 
be individual predisposition, since the ex- 
citing causes, if pollens, are everywhere. 
This predisposition or idiosyncrasy has 
generally suddenly developed without ap- 
parent reason. It has been argued that it 
is systematic or central, and that it is due 
to some local abnormality of the mucous 

[110 1 



ACCEPTED CAUSES 

membrane, the capillaries, or the periph- 
ery of nerves. Once acquired, however, it 
is seldom lost, and it apparently increases 
with each successive year. 

The influence of race is seen in the fact 
that the English-speaking people are the 
principal sufferers. In India, Africa, and 
Australia it is mostly the English and 
Americans who are attacked. In America 
it occurs in nearly every State, altho much 
more infrequently in the South. In Can- 
ada hay-fever is rare, especially in the 
maritime provinces. Wyman relates a 
case — the only one reported — of hay-fever 
in an Indian child. Beard mentions that 
Dr. Jacobi, of New York, who practised 
much among the Germans, had never met 
with a case in that nationality ; and in the 
same city a similar observation was re- 
corded by Dr. Chaveau, a practitioner 

among the French. Sajous has called at- 
[lin 



HAY-FEVER 

tention to a curious fact in this connec- 
tion — viz., that the principal sufferers, 
American and English, are excessive tea- 
drinking nations, and that this beverage 
may exert a depressing influence on nerve- 
centers. It would be interesting to have 
some information as to the existence of 
hay-fever in China and Japan, the tea- 
producing countries. John N. Mackenzie, 
in 1884, gives the first recorded instance 
of hay-fever in a negro, a male of thirty- 
five, tall, well-proportioned, and respect- 
able, the attack lasting from the second 
week in August to late in September. A 
sensitive spot was found on the left in- 
ferior turbinated bone, iy± inches within 
the nostril, which gave origin to a most in- 
tense paroxysm of asthma on simple con- 
tact with the probe. 

Eeports of hay-fever have come from 
nearly every quarter of the civilized globe. 

[112] 



ACCEPTED CAUSES 

It is seldom seen in the far North, and is 
more frequent in the temperate than in the 
torrid zone. It is seen more often in urban 
than in rural districts. The disease is by 
far the most frequent in Great Britain and 
the United States. In Norway, Sweden, 
and Denmark it is seldom found, and it is 
scarcely ever seen among the natives of 
Eussia, Germany, France, Italy, or Spain. 
The English and Americans in India and 
Africa are the only ones who are affected 
by it. Macdonald, in 1893, said the Irish 
are certainly not exempt. In the north of 
Scotland it is very infrequent, while in the 
south of England the disease is more fre- 
quently found than in the north. In Aus- 
tralia and New Zealand it is occasionally 
found. Literature is strangely silent about 
South America, but this land is strange to 
us in many other ways. Pirrie gives an 
instance of an English officer in India suf- 

[113] 



HAY-FEVER 

fering there when vegetation was alto- 
gether different from the forms met with 
in England where his attacks had begun. 
As already noted, the complaint has made 
its appearance in two instances when its 
victims were at sea; one, reported by Ab- 
botts Smith, after shaking out the sails 
when nine miles out at sea; and another, 
reported by Walshe, in which the patient 
suffered throughout a voyage across the 
Atlantic. A " sufferer" records that nu- 
merous portions of England, especially the 
highlands and the seacoast, and nearly all 
of Wales and Scotland are exempt from 
the disease. He also regards the upper 
side of the St. Lawrence Eiver, most of 
the province of Ontario north of the Wel- 
land Canal to the Detroit River similarly 
exempt, and he states that the disease is 
wholly unknown to regions above the out- 
let to Lake Huron. 

[114] 



ACCEPTED CAUSES 

Wyman has considered the regions of 
America where hay-fever is especially 
prevalent. That portion of country east 
of the Mississippi River and lying between 
the 35th and 45th parallels of latitude 
he regarded as the territory of prevalence. 
Canada and the Adirondack Mountains, 
the Appalachian range, and the elevated 
plateau throughout New York State 
he considered almost exempt from hay- 
fever. That portion of the United States 
west of the Mississippi River he seemed to 
think, as did Beard also in his later inves- 
tigations, was free from the disease. Beard 
based his reasons upon the lack of vegeta- 
tion and the sparseness of the population. 
Bosworth regards as better reasons the 
rugged mode of life of the inhabitants and 
the consequent vigorous health of the fron- 
tier life. It is a curious observation, too* 
that certain portions of the White Moun- 

[115] 



HAY-FEVER 

tains country, formerly regarded as in- 
variably free from hay-fever, of late years, 
probably owing to the extension of civili- 
zation and its vegetation to these regions, 
are no longer exempt from it. Southern 
climates, to a certain extent, are exempt 
from the disease. Wyman thought it did 
not prevail south of the 35th parallel of 
latitude, with the exception of certain 
districts in the neighborhood of Milledge- 
ville, Georgia, Montgomery, Alabama, and 
Beaufort, North Carolina. There can be 
little doubt that the affection is less com- 
mon in Maryland, Virginia, in the border 
States, and in the far West ; that it is rare 
in the extreme South and on the Pacific 
slope. The zone between the 35th and 
45th parallels of latitude practically in- 
cludes the hay-fever district. Even in this 
section, localities, from their proximities 
to large bodies of water or to oceans, to 

[116] 



ACCEPTED CAUSES 

elevation or to absence of certain vege- 
tation, afford immunity. A "sufferer" 
states that on Lake Michigan hay-fever is 
absent above Ludington, while on the Mis- 
sissippi, in Wisconsin, it is present as far 
north as the Chippewa Eiver, and in some 
seasons, in a mild form, it is seen in St. 
Paul, Minnesota. It is known to extend 
to the latitude of Memphis in the West, 
Knoxville centrally, and Cape Henry on 
the Atlantic. In 1896 W. W. Bulette stated 
that in certain sections of Colorado there 
is a variety of the affection known among 
laymen as blossom or cotton-wood fever, 
and very prevalent in regions where the 
cotton-wood tree abounds. The symptoms 
are practically identical with those of the 
autumnal variety of hay-fever, except that 
the throat and bronchial irritations are in- 
tensified, and the course of the attack is 
somewhat shorter. Symptoms occur about 

[117] 



HAY-FEVER 

the 12th of April and terminate in the 
latter part of May, and rarely last longer 
than July 1st. 

Beard's pamphlet was the first to show 
a radical departure from the pollen theory 
and to establish that the neurotic habit was 
an essential factor. He showed that sub- 
jects of hay-fever often acquired the af- 
fection or the tendency to it through in- 
heritance. The facts sustaining this view 
are of "a most overwhelming character/ p 
Wyman, himself a sufferer, records nu- 
merous cases in his own family through 
four generations. He proved the powerful 
influence of heredity in many of his cases. 
It even appears in childhood, he states, 
and quite generally in those of nervous 
diathesis. In Dr. MorelPs family there 
were six sufferers from hay-fever besides 
himself. In the family of Henry Ward 
Beecher there were two besides himself; 

[118] 



ACCEPTED CAUSES 

and Chief Justice Shaw's family contained 
seven. Bosworth says that eighteen of 
eighty cases disclosed direct heredity, 
while in thirty-nine there was either hay- 
fever or asthma in the family. Of the 
forty cases of Sajous', thirty-five per cent, 
had near relatives who presented clear his- 
tories of hay-fever, and forty-two per cent, 
had asthmatic relatives, while fifty-three 
per cent, of these cases presented a fam- 
ily history of either hay-fever or asth- 
ma. Morell Mackenzie has several times 
treated father and children for hay-fever 
at the same time. Prince relates that five 
members of the same family were hay- 
fever subjects. One daughter of thirty 
years suffered with June cold ever since 
she was five years of age, every year save 
1887, 1888, and 1889. Her grandmother, 
mother, and two brothers suffered alike. 
The daughter, convinced that mental or 

[119] 



HAY-FEVER 

nervous influence affected her, in 1887 was 
treated by the "mind cure," and for three 
years subsequently was free from her 
symptoms. When the original mind curist 
was dead, in the fourth year, the symp- 
toms returned as badly as ever. Chris- 
tian Science influence was tried in vain. 

There can be little doubt that males are 
more afflicted than females. Of the early 
forms of the disease, however, females 
seem more susceptible than males. Of 433 
cases cited by Phoebus, Wyman, and Beard, 
only 142, about one-third, were females. 
Of 506 cases gathered from several au- 
thors, 342 were males, 164 females. Morell 
Mackenzie met with 38 cases in males and 
23 in females. Men are the more exposed 
to the exciting causes such as dust, heat, 
pollen, etc., altho females are the more 
neurotic. The proportion is about one fe- 
male to three males. 

[120] 



ACCEPTED CAUSES 

Only to some extent can age be said xo 
affect the disorder. The liability to hay- 
fever in the great majority of cases ap- 
pears before the age of forty. The malady 
has been reported, however, as occurring 
for the first time in persons as old as 
sixty, and persons of seventy and upward 
have suffered. Of the cases of children 
who have been attacked the disease had 
manifested itself in the parents. It would 
have probably been regarded as a common 
cold, had not the parents been the subjects 
of the affection. 

Most all writers on this subject have ob- 
served that the disease attacks the better 
educated classes and those of fair social 
position. It is rarely met with among the 
laboring classes. This would seem to em- 
phasize the view that the disease is essen- 
tially a neurosis. From the notes of sixty- 
one cases of hay-fever in private practise, 

[121] 



HAY-FEVER 

and the sight of many others of which no 
record was kept, Morell Mackenzie found 
all the patients persons of some education, 
and recalled having seen none among his 
hospital patients. Of forty-eight cases of 
Blackley, all were educated, and "Wyman 
made the same observation. Holmes has 
shown that the ignorant classes are not so 
likely to recognize the disease as a distinct 
affection, and apply for medical aid 

The fact that the rustic is much less sub- 
ject to this disease than the dweller in the 
city and town, shows the influence of the 
mode of life. Farmers and agriculturists, 
exposed, it would seem, far more to the ex- 
citing causes than others, are peculiarly 
less liable to suffer from it. Beard reports 
only seven such cases among 200. Morell 
Mackenzie states that it is impossible to 
tell whether the villager owes his exemp- 
tion to the maintenance of vigorous health 

[122] 



ACCEPTED CAUSES 

by an outdoor life, or to habitual exposure 
to the cause of the complaint. 

Holmes admirably points out that "a 
part of the mysterious origin must be set 
down to the indifference of the sufferers 
who, from year to year, have forgotten 
their periodical affection and failed to con- 
sult physicians/ ' He says: "Of similar 
cause is the groundwork of the assertion 
that it affects only the wealthy. This is 
simply because with this class there is a 
higher intelligence and closer attention to 
ailments, and the fact that having once dis- 
cerned the actual condition, they, in many 
instances, take professional advice or go to 
a place of refuge, thus drawing notice to 
themselves, all of which things are denied 
to the lower (poorer) classes. It is said 
that there are some 200,000 sufferers in the 
United States, at least within the range of 
observation of the Hay-Fever Association, 

[123 1 



HAY-FEVER 

which, meeting annually at Bethlehem, 
N. H., may be held to represent the more 
stable and well-to-do. From my own ex- 
perience and observation I am convinced 
that there are many of our working peo- 
ple who suffer from this affection who do 
not even recognize the disease." Mer- 
chants, professional men, persons of sed- 
entary habits and brain-workers supply 
most of the victims. The disease is not 
so uncommon among hospital outpatients 
here and in England as formerly. 

Concerning the influence of the neurotic 
tendency, Beard pointed out, in 1876, two 
popular misconceptions of the nervous 
theory, first, that nervous susceptibility 
implies debility and emaciation, whereas 
the nervous temperament is consistent 
with great strength and power of endur- 
ance, especially when combined with the 
bilious and sanguine temperaments; and, 

[124] 



ACCEPTED CAUSES 

second, that the nervous theory dispenses 
entirely with the influence of exciting 
causes, as heat, pollen, etc. Beard con- 
cluded that the disease is a complex re- 
sultant of a nervous system especially sen- 
sitive in this direction and acted upon by 
the enervating influence of heat and by 
any one or several of a large number of 
vegetable and other irritants, and this 
view has the advantage over other theories 
in that it accounts for all the phenomena 
exhibited by the disease in this or in any 
other country. He believed that the trans- 
missibility of the disease from parents to 
children; the temperaments of the sub- 
jects; the capricious interchange of the 
early, the middle, and the later forms ; the 
periodicity and persistence of the attacks 
and their paroxysmal character ; the points 
of resemblance between the symptoms and 
those of ordinary asthma; the strange 

[125] 



HAY-FEVER 

idiosyncrasies of different individuals in 
relation to the different irritants ; the fact 
that it is a modern disease peculiar to 
civilization; the fact that it most abounds 
where functional nervous disorders are 
most frequent and is apparently on the in- 
crease pari passu with other nervous dis- 
eases; and, finally, the fact that it is best 
relieved by those remedies which act on 
the nervous system, — all these otherwise 
opposing and inconsistent phenomena are 
by this hypothesis fully harmonized. 
Prince remarks that altho a nervous orig- 
gin has been recognized by some, still no 
theory has been proposed to show the con- 
nection between the physical symptoms 
and the nervous processes nor the pathol- 
ogy of the nervous processes themselves. 

Vasomotor susceptibility has been viewed 
as indicating the neurotic tendency, and 
this may or may not be due to a central 

[126] 



ACCEPTED CAUSES 

lesion. John N. Mackenzie regarded dis- 
ordered functional activity of the nerve- 
centers as the expression of the nervous 
origin. Again, a general neurosis dispos- 
ing to vasomotor disturbance of the sym- 
pathetic and the trigeminus nerves has 
been held responsible. Kinnear speaks of 
two forms, — one a hyperemia, and the 
other an anemia of the sympathetic gan- 
glion. Bosworth is inclined to think a 
peculiar lack of vasomotor control charac- 
terizes the neurotic manifestations. In 
asthma there is undoubted vasomotor pa- 
resis of the blood-vessels of the bronchial 
mucous membranes, while in hay-fever it 
is of the nasal mucous membranes. 

Solis-Cohen regards hay-fever as gen- 
erally a neurosis, primarily a vasomotor 
ataxia or idiosyncrasy. Another view is 
that it may be due to an organic alteration 
of the nerve-fibers terminating in the nasal 

C127] 



HAY-FEVER 

region and chiefly in three reflex areas. 
Again, that it may be due to functional 
activity or paresis of the governing (vaso- 
motor) centers, accompanied by hyperex- 
citability of the erectile (cavernous) tis- 
sues aroused by peripheral irritation. The 
phenomena of the cavernous nasal tissue, 
tho secondary to the centric condition, 
indicates a vasomotor disease. Hack and 
Robinson believe the morbid lesion is one 
of neurotic disposition with hyperesthetic 
condition of the olfactory and fifth pair of 
cranial nerves. 

Analogous to the neurotic habit is idio- 
syncrasy. Apparently the same under- 
standing as to what an idiosyncrasy is has 
underlain the use of this word by various 
writers who have advanced idiosyncrasy as 
a cause of hay-fever. Morell Mackenzie, in 
1880, put it down as a predisposing cause, 
but does not say upon what the idiosyn- 

[128] 



ACCEPTED CAUSES 

crasy depends, whether upon some local 
abnormality, the capillaries, the nerve- 
centers, or the periphery of the nerves. 

In 1897 S. Solis-Cohen said idiosyncrasy 
is a real condition in hay-fever, and cited 
the idiosyncrasies to salicylic acid, qninin, 
ipecac, opium, etc., as similar to idiosyn- 
crasies that patients exhibit toward the 
different irritants capable of producing 
hay-fever. Using the word to express the 
fact that certain persons react differently 
from most of mankind to certain forms of 
irritation, it means something. It means 
that such persons are abnormal, altho the 
cause of the abnormality remains to be dis- 
cerned. Holmes, speaking of idiosyncrasy, 
would not say there is no such thing as 
idiosyncrasy, but as far as hay-fever went, 
he held that the disease was an actual one, 
the nature of which was not yet com- 
prehended. He remarks that it is quite 

[129 1 



HAY-FEVER 

probable that uric acid would aggravate 
hay-fever as it would any other condition 
in the body; and that some think to have 
proved this by the use of salicylic acid, to 
which drug many persons have an idiosyn- 
crasy, thereby aggravating the condition 
in hay-fever by the elimination of uric acid. 

Dr. Samuel Ashhurst, in 1897, recorded 
his habit of regarding hay-fever of late 
years as a personal idiosyncrasy acted 
upon by some irritant, and observed that 
without this personal element it is diffi- 
cult to account altogether for the symp- 
toms and their peculiar periodicity. 

In 1882, Daly advanced the theory of the 
local disease as causative of hay-fever, and 
reported a case in which the patient recov- 
ered after the removal of a nasal polyp, 
which by continuous mechanical irritation 
had doubtless given rise to the condition 
underlying. Examinations of the nares of 

[130] 



ACCEPTED CAUSES 

hay-fever patients have repeatedly failed 
to show any local disturbance other than 
general congestions. Daly's theory was 
subsequently accepted and supported by 
Hack and Eoe, who both affirmed that the 
influence of a morbid condition of the nasal 
mucous membranes favored the develop- 
ment of hay-fever. In 1883 Sajous and 
Herzog wrote important papers to prove 
the same facts. In 1884 J. N. Macken- 
zie demonstrated that " there exists in 
the nose a well-defined sensitive area 
whose stimulation through a local patho- 
logic process, or through an extra irrita- 
tion, is capable of producing an excitation 
which finds its expression in a reflex 
act or in a series of reflected phenomena/ ' 
He located this area at the posterior end 
of the inferior turbinated bones and corre- 
sponding portion of the septum. It has 
since been held by advocates of the local 

[131] 



HAY-FEVER 

theory, that diseases and abnormalities of 
the nose, such as a markedly deviated sep- 
tum, outgrowths from the septum, hyper- 
trophic rhinitis, enlargement of the in- 
ferior or middle turbinated bodies, mucous 
polypi, and marked turgescence of caver- 
nous tissue on the inferior turbinated 
body, were all provocative of hay-fever 
paroxysms. 

In 1884, Harrison Allen declared that 
the primary lesion was one of obstruction, 
temporary or permanent, in one or both 
nostrils, from one of various causes, at- 
tended by vascular dilatation. Bosworth 
likewise held that the existing morbid con- 
dition of the intranasal tissues must be one 
of an obstructive character, tending to pro- 
duce in itself vascular dilatation. Regard- 
ing nasal polypi, occasionally considered 
as active causes of hay-fever, Bosworth 
concludes that they are rather a result 

[132] 



ACCEPTED CAUSES 

than a cause, since the great quantity of 
outpoured serum makes the nasal mucous 
membrane sodden or water-soaked, and 
in this way myxomatous degeneration de- 
velops, eventually assuming the form of 
polypi. 

J. N. Mackenzie, however, examined the 
nares of many sufferers from hay-fever 
without finding any nasal lesion. Holmes 
noted an instance most carefully reported, 
in which, with cold snare and galvanocau- 
tery, all obstructions were removed, and 
areas rendered anesthetic so that a probe 
no longer excited reflex symptoms, yet 
the patient suffered from hay-fever with 
scarcely diminished intensity. He further 
observes that at least a degree of the con- 
dition might be the result and not the 
cause, the peripheral susceptibility being 
an outward expression of an inward state. 

In 1885, Thornwaldt, in Wiesbaden, in 

[133] 



HAY-FEVER 

his observations on nasal catarrh, assumed 
that nasopharyngeal disease might not 
only give rise to symptoms simulating 
nasal disease, but was likely the actively 
predisposing cause of asthma and hay- 
fever. Bosworth agreed with him as far 
as hay-fever is concerned. 

In 1893 Seth S. Bishop announced to the 
American Medical Association that "an 
excess of uric acid in the blood causes hay- 
fever, or nervous catarrh." Uric acid in 
the blood in marked excess of the normal 
relation to urea, of about one to thirty- 
three, causes certain disturbances of a vas- 
cular and neurotic character. In health, 
five to eight grains of uric acid are se- 
creted every twenty-four hours. Haig 
claimed that an effect of an excess of uric 
acid is contraction of the arterioles and 
capillaries all over the body. He found 
that by diminishing the alkalinity of the 

[134] 



ACCEPTED CAUSES 

blood it was freed from uric acid, the arte- 
rioles were relaxed, and the headaches and 
mental depression were relieved. Cerebral 
anemia has appeared to obtain in hay- 
fever, and the attacks were relieved, Haig 
found, by such remedies as relieved anemia 
of the brain, e.g., amyl nitrite, coffee, and 
other cerebral stimulants. These views of 
Haig were concurred in by Thomas J. 
Mays, Murchison, Conklin, Ebstein, Quin- 
quaud, and others. Bishop, in 1894, re- 
marked that the blood in the morning is 
more alkaline than at any other time of the 
day, being, at about nine o'clock, at its 
greatest point of alkalinity, which would 
seem to account for those attacks of hay- 
fever which came on early in the morning, 
and which in some instances were as- 
cribed to the influence of light. He was of 
the opinion that not only an excess of uric 
acid in the system, but also an increased 

[135] 



HAY-FEVER 

formation thereof should be regarded in 
the treatment of hay-fever. Bishop also 
claimed that the uric-acid theory was not 
antagonistic to the essentially neurotic 
character of the disease. He also ad- 
vanced that the primary determining cause 
of the particular manifestations in this 
disease is an inherent, perhaps hereditary, 
susceptibility of the nervous system. In 
this way only can we account for the fact 
that the same subjective or objective ex- 
citing cause (uric acid or pollen) will pro- 
duce one train of distressing symptoms 
(nervous coryza) in one individual, and an 
entirely different one in another (asthma). 
This uric-acid hypothesis explains why 
some persons suffer from attacks under 
certain conditions in winter as well as dur- 
ing the warm months. It also unifies all 
the forms. 
Bishop says: "The uric-acid theory of 

[136 ] 



ACCEPTED CAUSES 

hay-fever is not antagonistic to the present 
status of medical opinion or surgical treat- 
ment, but, on the contrary, it explains 
questions that were inexplicable before. 
As a tumor or hypertrophied bone may 
give rise to convulsive seizures in epilepsy, 
and as its removal may be followed by re- 
lief when no other structural cause ex- 
ists, so in hay-fever, when new growths 
and other lesions of the nasal mucous 
membrane are present, the attack may be 
started by the accumulation and the sud- 
den setting free of uric acid. This pre- 
cipitates the paroxysm by its irritant ac- 
tion, which finds expression in the group 
of symptoms characteristic of hay-fever 
or asthma, instead of some one of the other 
allied diseases. The particular form of 
manifestation may be determined by the 
growth or the seat of irritation located in 
the nasal cavities. When this is the only de- 

[137] 



HAY-FEVER 

termining factor of the nature of the mor- 
bid symptoms, no other disease having re- 
sulted from the long-standing trouble, the 
removal of such a peripheral source of 
irritation may give relief from these 
symptoms, but it may not prevent the 
uricacidemia from switching off into other 
kindred lines of disturbances, if it be not 
corrected/ ' 

Capp, in advancing a new theory, in- 
clines to the uric-acid theory, and alludes 
to a certain spastic condition not men- 
tioned by other writers, which, altho slight 
in character, is general, rather than con- 
fined to limited areas, and in a large meas- 
ure accounts for many manifestations of 
the disease. A central nervous irritation 
is probably caused by the presence of a 
disturbing element in the blood, presum- 
ably products of imperfect metabolism not 
eliminated. This may originate nerve-cur- 

tl38] 



ACCEPTED CAUSES 

rents with innumerable reflexes, which, in 
the disturbed equilibrium of the system, 
are, in a measure, uncontrolled by the or- 
dinary inhibition. 

Holmes has very cleverly pointed out a 
fallacy in regard to the evidence advanced 
to substantiate the uric-acid theory. He 
states that some investigators by the use 
of salicylic acid and various acids to 
diminish the alkalinity of the blood, thus 
eliminating uric acid, have, thereby, ac- 
tually aggravated the condition in hay- 
fever, which aggravation has been thought 
due to excess of uric acid in the tissues, or 
increase in its production, instead of be- 
ing due to the idiosyncrasy to salicylic 
acid, etc. 

In 1897, Grayson stated that even if we 
grant that a certain number of hay-fever 
patients are unquestionably people of a 
neurotic temperament, while others are 

[139] 



HAY-FEVER 

gouty, can not we profitably look beneath 
these titles and recognize the fact that they 
are dyscrasies, which are merely different 
offshoots from a parent weed that is 
rooted in defective nutrition? By defec- 
tive nutrition is meant all the phenomena 
of metabolism, — constructive, destructive, 
and eliminative. Disturbance of one means 
disturbance of all. With continued ab- 
sorption of toxic materials from the intes- 
tinal tube, or with persistent incomplete 
elimination of the products of suboxida- 
tion, it is only a question of time when au- 
totoxemia will provide us with any of the 
functional neuroses from hay-fever and 
asthma to chorea and epilepsy. 

Grayson says the neurotic habit may ex- 
ist, but it is not essential to the disease, but 
the nervous system is implicated as a vic- 
tim, not as a culprit. He claims that hay- 
fever is a defect, not of the nervous, but of 

[140] 



ACCEPTED CAUSES 

the nutritive system, because impairment 
of the digestive and nutritive processes is 
almost invariably the first downward step 
toward a general state of lowered vitality. 
At first gastric, it later involves the whole 
gastro-intestinal tract. He thinks uric acid 
is almost invariably present in excess in 
hay-fever subjects. A child having reflex 
convulsions due to acute indigestion is not 
a neurotic subject, yet the vasomotor per- 
turbation of the hay-fever patient differs 
from that of the child mainly in point of 
chronicity. 

Grayson concludes that the three factors 
which make up the etiologic combination of 
hay-fever are : An external irritant, some 
intranasal abnormality, and a constitu- 
tional element — ' i defective nutrition. ' ' 
The physician unaided can not restore the 
nose to a state of health. In order to over- 
come the self-indulgence of the patient, 

[141] 



HAY-FEVER 

regularity is recommended in eating, work, 
and play, while indiscretions of diet, lack 
of exercise, objectionable fancies in mat- 
ters of clothing and bathing, and, finally, 
vicious excesses — alcoholic, narcotic, or 
sexual — will require the constant and most 
determined effort of the patient himself. 
The whole environment of the patient must 
be separately studied and provided for in 
the dietary scheme. A comment on this 
treatment is: " While it is true that if a 
man takes care of his muscles his nerves 
will take care of themselves, there is no 
closing of the eyes to the fact that to the 
average man exercise is distasteful ; there- 
fore, it is the more necessary to be explicit 
in instructions concerning it. Altho there 
is nothing brilliant about this method of 
removing the constitutional factor of the 
disease, what it lacks in brilliancy is more 
than made up in certainty, and if the 

[142] 



ACCEPTED CAUSES 

patient is possest of grit and determina- 
tion it brings a sure reward/ ' 

J. Miiller thinks there is a causal rela- 
tion between hay-fever and gastrointes- 
tinal symptoms, but he also holds that it 
can be proved that pollen entering the 
respiratory tract is the cause of the dis- 
ease. A "sufferer," writing on the dis- 
ease, says: "Indigestion is a most potent 
cause in many instances, and proper food, 
properly digested and assimilated, has 
permanently relieved more than one." But 
he does not say he himself was relieved, 
nor does he give cases. 

It is questionable whether or not the di- 
gestive disturbances are not effects rather 
than causes of the disease. It is not at all 
doubtful, however, that lowered resistance 
and a depreciated vitality may result from 
difficulty in the gastro-intestinal tract. 
Such difficulty may suffice to start the 
chain of hay-fever symptoms. 

[143] 



PART III 
FOEMS OF TEEATMENT 



1 145 j 



PART III 

FOEMS OF TREATMENT 

1. Preventive Measures 
In the young we find preventive treat- 
ment giving the greatest rewards. This 
calls for careful attention to the general 
health of the growing child. The medical 
profession has done much to awaken an 
interest in preventive measures among 
parents, and in no way has the family phy- 
sician reduced infection more thoroughly 
than by insisting on a careful toilet of the 
nose and throat. In this way he has very 
frequently prevented many of the more 
serious diseases of the growing child. Per- 
sonal hygiene is as valuable as domiciliary 
hygiene, yet, if either is neglected disease 
is certain to continue. 

[147] 



HAY-FEVER 

The careful parent will insist upon fre- 
quent professional examinations of their 
children and at the first sign of discomfort 
have any abnormal condition corrected. It 
is not wise to wait until distress compels 
relief, and if hay-fever is an inheritance in 
a. family it is especially important. Chil* 
dren with enlarged tonsils and adenoids 
should have them removed not only to in- 
crease their mental poise but to secure their 
physical comfort, and also as a step in 
escaping hay-fever. Adenoids are fre- 
quently the cause of broken rest at night, 
with earache, a tendency to repeated bron- 
chitis ; this is seen more frequently during 
spring and fall. This condition may bring 
on change in voice and ofttimes a running 
nose. With enlarged tonsils we frequently 
encounter the unproductive cough. We 
may mention, while passing, that enlarged 
tonsils remaining after the tenth year 

[148] 



FORMS OF TREATMENT 

should be removed, as they are undoubt- 
edly hopelessly diseased. I am a firm be- 
liever that tonsils and adenoids should be 
removed early, for, in addition to this lo- 
cal discomfort they influence the mental 
health by rendering possible a more sys- 
temic depreciation of the child. The fron- 
tal sinus may become involved as well 
as the ethmoid. Young children are fre- 
quently found to suffer with deviated sep- 
tum and this contributes to the general dis- 
comfort. With the pressure of retained 
secretion polypi are not unusual. 

Ballinger has been imprest with the 
possible relationship of catarrhal sinusitis, 
particularly ethmoidal and frontal, to hay- 
fever. He has found surgical treatment 
of the sinusitis to be followed by relief of 
the hay-fever. The difficulty in the way of 
diagnosticating catarrhal sinusitis has been 
so great that it has been frequently un- 

[149] 



HAY-FEVER 

recognized. Hay-fever due to catarrhal 
sinusitis has been cured by Dr. P. M. Far- 
rington, of Memphis, by the use of auto- 
genous vaccine. 

Dr. Ballinger quotes the late Dr. Scha- 
dle, who called attention to the possibility 
of relationship between maxillary sinusitis 
and hay-fever. "Whether or not such a re- 
lation exists, we must recognize the fact 
that the local hyperesthesia probably has 
an anatomical or inflammatory origin. The 
hypersensitiveness does not "happen' ' but 
has a definite cause. The hypothesis is still 
further supported by clinical facts — that 
some cases of hay-fever are cured by suc- 
cessful treatment of the sinusitis. Hered- 
ity may impress a neurotic temperament 
on the growing child with tendency to gout 
or rheumatism. This unstable condition 
of the nervous system is difficult to define, 

there may be an excess or decrease in the 
[ 150 ] 



FORMS OF TREATMENT 

nervous energy. There may be a faulty 
metabolism whereby certain toxic sub- 
stances are liberated in the blood current. 
That hay-fever subjects are usually neu- 
rotic has been generally accepted. "Why 
they are neurotic is a much mooted ques- 
tion, concerning which ingenious theories 
have been advanced, but none of which are 
convincing. 

Preventive treatment for hay-fever, 
therefore, must take in family history and 
family tendency in an endeavor to correct 
local, as well as constitutional faults. This 
intimate knowledge of family history gives 
the physician the insight to the constitu- 
tion of the child. Heredity may do much 
to balance or unbalance nervous energy, it 
may do more to handicap a child physi- 
cally, but I am of the opinion that environ- 
ment plays a most important role in the 
growing child. In childhood preventive 

[151] 



HAY-FEVER 

measures yield the best returns, and this is 
well illustrated in the development of hay- 
fever tendency, and it is wise that the 
masses have grown active to the needs of 
the young. 

As an important feature in preventive 
measures I can do no better than quote 
here the article of Dr. Scheppegrell, the 
president of the American Hay-Fever Pre- 
vention Association, on " Hay-fever; Its 
Cause and Prevention/' 1 

1 i From the standpoint of the number of 
patients affected, hay-fever ranks among 
the first of the non-fatal diseases. While 
accurate statistics regarding the number 
of patients are not available, a conserva- 
tive estimate has placed the number of 
persons in New Orleans affected with hay- 
fever at not less than 3,500, or one per 

1 Published in the Journal of the American Medical 
Association for March 4, 1916. 

[152 ] 



FORMS OF TREATMENT 

cent, of the total population. Hay-fever is 
prevalent in the greater portion of the 
United States, and the proportion in New 
Orleans is a fair average of its prevalence 
in other sections. The total number of 
those suffering from this disease, there- 
fore, is so large that the subject demands 
the most careful consideration. 

"In spite of the greater increase in med- 
ical knowledge, many cases of hay-fever 
are still mistaken for ordinary colds. The 
symptoms described and their recurrence 
at certain periods of the year should sim- 
plify the diagnosis. In doubtful cases, this 
may be confirmed by testing the patient 
with a small amount of pollen. 

"Some of the staminate flowers of the 
suspected plant are placed in a small sterile 
gauze-bag, and this gently sniffed by the 
patient. In susceptible subjects this is 
quickly followed by a slight reaction. The 

[153] 



HAY-FEVER 

patient may also be tested by approaching 
the suspected weeds so that some of the 
pollen is inhaled in this way. 

"In the majority of cases, however, 
these tests are unnecessary and should or- 
dinarily be avoided on account of the dan- 
ger of developing a latent pollinosis. The 
beginning and end of the attacks are 
usually found to be coincident with the pol- 
linating period of certain plants with 
wind-borne pollen, which, with the symp- 
toms described above, is sufficient to con- 
firm the diagnosis. 

"Some physicians still believe that hay- 
fever is a local manifestation of some con- 
stitutional condition, in spite of the fact 
that the majority of patients, with similar 
conditions, have no such manifestations, 
and that when the pollen is not present, as 
on a sea trip, they do not occur. Improved 
education in the etiology of this disease, 

[ 154] 



FOEMS OF TREATMENT 

and more careful observation, will grad- 
ually correct this error, 

"Even had therapeutic measures been 
more successful, prophylaxis, based on the 
removal of the exciting cause, should have 
been advocated as in malarial and typhoid 
fevers, tuberculosis and other diseases of 
known cause. Hay-fever, however, has 
been the step-child of preventive medicine, 
and until recently no organized efforts in 
this direction have been undertaken. 

"In view of the great and increasing 
number of hay-fever patients, their pro- 
longed distress, the unsuccessful results of 
all curative measures and the distinctive 
preventable character of the disease, the 
American Hay-Fever Prevention Associa- 
tion has undertaken a campaign of edu- 
cation, to be followed in due time by 
suitable legislation, for the prevention of 
hay-fever. 

[155] 



HAY-FEVER 

"In the educational part of this work, 
the first consideration is the correct diag- 
nosis of hay-fever and the acceptance of 
the fact that all cases of true hay-fever are 
the results of pollen inhalation. 

"The identification of the various weeds 
and plants that may develop hay-fever is 
of the utmost importance, but will grad- 
ually follow the establishing of the etiol- 
ogy of pollinosis. As these principles 
become better understood, the physician, 
when consulted by a patient with hay- 
fever, instead of limiting his attention to 
writing a prescription or injecting a vac- 
cine, will investigate the presence of hay- 
fever-producing weeds in the neighbor- 
hood of the patient's residence or vocation. 
In many cases the eradication or even the 
cutting of such weeds produces immediate 
results. 

"In one of my patients, the offending 

[ 156 ] 



FORMS OF TREATMENT 

weed, Ambrosia artemisice folia [rag- 
weed] was growing in his garden. In an- 
other, a school-teacher, affected with hay- 
fever for many years, on being questioned 
stated that there was an abundance of 
flowering weeds in the vacant lots adjoin- 
ing her house. When specimens of these 
weeds were produced they were found to 
be the Parthenium hysterophorus, one of 
the causes of hay-fever in South Louisiana. 
In both of these cases marked relief soon 
followed the cutting of these weeds. In 
order to obtain complete relief in such 
cases, however, the cutting of the weeds 
should be over a considerable adjoining 
area, as the pollen is wind-borne to a 
distance depending on the velocity of the 
wind. 

" While the removal of the offending 
weed is the correct measure, relief may 
also be obtained, when this is impractica- 

[157] 



HAY-FEVER 

ble, by avoiding the proximity of weeds 
known to be toxic to the patients. In many 
cases tliis is entirely .practicable, as shown 
in the following case in which the attack 
was postponed for thirty-three days: 

^E. G., manager of a sugar plantation 
near New Orleans, has been a sufferer 
from hay-fever for the past ten years, the 
attacks always commencing about August 
25th. After the influence of the ragweed 
to this form of hay-fever had been ex- 
plained to him, he concluded that his at- 
tacks were due to the pollen of the trifida 
ragweed which grows on a road some dis- 
tance from his residence. He, therefore, 
avoided the road, and until September 
28th, for the first time in ten years, he had 
had no attack. On this date he found it 
necessary to pass this road. In twenty 
minutes he commenced to sneeze, that 
night he had a violent attack, and the fol- 

I 158 ] 



FORMS OF TREATMENT 

lowing day he had his usual annual hay- 
fever. 

"The treatment of cases by the eradica- 
tion of the hay-fever-producing weeds will 
not only produce direct results, but will 
also prove a powerful impetus in educa- 
ting the public in the relationship of such 
weeds to hay-fever. It will result, more- 
over, in having these weeds considered 
from a new point of view. Instead of sim- 
ply indicating neglect or careless cultiva- 
tion, they will be looked on as a source of 
disease and discomfort to a large class of 
sufferers. This will not only bring the 
leverage of public opinion to the eradica- 
tion of these weeds, but will eventually 
simplify the question of legislation. 

"In connection with the question of pub- 
lic education, the American Hay-Fever 
Prevention Association has received a 
communication from Dr. Rupert Blue, sur- 

[159] 



HAY-FEVER 

geon-general of the United States Public 
Health Service, and one of the honorary 
vice-presidents of our association, in which 
he summarizes this in a very concise 
manner : 

" 'It appears that the most practical 
method of securing the cooperation of the 
public would be by education as to the ef- 
fect of the presence of these weeds in com- 
munities from both health and economic 
standpoints. This seems to be the pri- 
mary object of your association, which is 
to be commended for its efforts.'* 

"Some of the early forms of hay-fever 
are due to the pollen of the Graminacece 
or grasses, which include the cultivated 
varieties, such as rye, wheat, corn, etc. 
These form a common cause of hay-fever 
in England and the Continent, where the 
autumnal form due to the ragweed is not 
found, owing to the absence of the weed. 

[160] 



FORMS OF TREATMENT 

" While this is of much less frequency 
than the fall hay-fever in the United 
States, it represents in the aggregate a 
considerable number. When these cases 
are due to the cultivated varieties, the 
knowledge of this fact should induce the 
patient, whenever possible, to live away 
from such cultivated fields or at least to 
avoid them during the active season of pol- 
lination. Only in those cases in which the 
removal of the offending plant is impossi- 
ble will the question of treatment be given 
preference over prevention. 

"As the autumnal hay-fever is the most 
prevalent form in the United States, and, 
in the majority of cases, is due to rag- 
weed, the American Hay-Fever Preven- 
tion Association has given its first atten- 
tion to the eradication of this weed. The 
description and illustration of both varie- 
ties (Ambrosia artemisicefolia and trifida) 

[161] 



HAY-FEVEK 

have been sent to the State boards of 
health of each State and of the District of 
Columbia. Many of these have published 
the cuts and descriptions, and a number 
have sent them to the newspapers of their 
State for publication. 

"The United States Department of Ag- 
riculture has assisted and is furnishing 
valuable information for this work. Ar- 
rangements have been made with the Hy- 
gienic Laboratory of the Public Health 
Service at Washington to make investiga- 
tions on the hay-fever pollens submitted 
by our research department. Encourage- 
ment or promise of active cooperation has 
been offered by the majority of the State 
boards of health, these being as follows: 
Arkansas, Alabama, Arizona, California, 
Colorado, Delaware, Florida, Idaho, In- 
diana, Iowa, Kansas, Kentucky, Louisiana, 
Massachusetts, Michigan, Minnesota, Ne- 

[162] 



FORMS OF TREATMENT 

vada, New Hampshire, New Jersey, New 
York, North Carolina, Oregon, Tennessee, 
Utah, Virginia, Washington, West Vir- 
ginia, Wisconsin and Wyoming. 

"The common ragweed (Ambrosia arte- 
misicefolia), while found in great abun- 
dance, presents no special difficulty in 
eradication, as it is an annual and repro- 
duced only by seed. In carefully cultivated 
lands it is not found in appreciable quan- 
tities. Where the land is not cultivated 
this weed may be entirely kept down by 
grazing cattle. When, however, it has been 
neglected, the weed should be mowed be- 
fore the latter part of August, in order to 
prevent pollination. 

"The giant ragweed (Ambrosia trifida), 
which grows in similar abundance in the 
moist lands of the coast, presents a more 
difficult problem, as the roots are peren- 
nial. Until this weed is two feet in height 

[163] 



HAY-FEVER 

cattle will feed on it with avidity, which 
will probably prove useful in destroying it. 
In carefully cultivated lands it is rarely 
found. The question of the best scientific 
method of eradication of both the rag- 
weeds has been referred to the United 
States Department of Agriculture, and the 
results of this investigation will be re- 
ported later. 

"With a view of showing what can be 
accomplished by organized efforts in the 
prevention of hay-fever, the American 
Hay-Fever Prevention Association has 
concentrated its first efforts in New 
Orleans in the following manner: 

"The public was first educated regard- 
ing the ragweeds, so that they could be 
easily recognized. Illustrations of the 
weeds were published in the Bulletin of the 
State Medical Board of Health and the 
public press, and the live weeds, in full de- 

[164] 




Q 

o 
o 

w 

Q 

< 
W 




FORMS OF TREATMENT 

velopment, were exhibited in a show-win- 
dow of the principal street. 

"The city of New Orleans, through the 
commissioner of public works, placed at 
the disposal of the association twenty con- 
victs, who cleared the streets and side- 
walks of the outer sections of the city of 
the weeds, in accordance with a map pre- 
pared by the topographic committee of 
the association, showing the areas infect- 
ed with ragweed. The city board of 
health assisted by enforcing the cutting of 
weeds in vacant lots and the commission- 
ers of the various parks had the ragweed 
destroyed in the public parks under the 
direction of the association. 

"Valuable assistance was given by the 
Women's Civic League, which appointed a 
special committee on vacant lots. This 
committee made arrangements with labor 
bureaus so that it not only reported lots 

[165] 



HAY-FEVER 

infected with weeds but offered to send 
workmen to cut them at low rates. 

"The storm of September 29 destroyed 
practically all the leaves and flowers of 
the remaining giant ragweed in exposed 
places. As a result of this, and the efforts 
of the American Hay-Fever Prevention 
Association, fall hay-fever practically dis- 
appeared in New Orleans several weeks 
earlier than the usual time. This cam- 
paign will be resumed next spring, when 
its management will be placed in the hands 
of the State Hay-Fever Association. 

"The American Hay-Fever Prevention 
Association believes that what has been 
effected in New Orleans can be done in all 
towns and cities. In some of the smaller 
towns, especially those catering to summer 
visitors, this could be accomplished before 
next summer. The statement that a town is 
free of hay-fever will prove an advertise- 

[166] 



FORMS OF TREATMENT 

ment that will easily repay the cost of de- 
stroying the hay- fever-producing weeds/ ' 

2. Local Treatment by Nasal 
Applications 

Local treatment of hay-fever has been 
viewed with diverse opinions by every 
writer on the subject. Many good authori- 
ties condemn all internasal treatment as 
useless and irritating, while others strongly 
advocate its value. It needs no argument 
to show the value of nasal and throat ap- 
plications of antiseptic nature in the early 
stages of influenza or any other neutral 
catarrhal irritation of the eye, nose or 
throat. Indeed many household epidemics 
have been shortened or aborted by the 
careful attention to these parts. I am not 
alone in the statement that severe house- 
hold epidemics have been deprived of their 
danger by careful cleansing of the nasal 

[167] 



HAY-FEVER 

mucous membrane before the infection be- 
came systemic. Indeed this is the routine 
treatment in every well-regulated family 
where children are found, especially dur- 
ing winter and spring, and in the early 
fall. It is much more important that this 
should be carefully observed if the neigh- 
borhood is infested with an epidemic of 
catarrhal colds. The repeated infection 
of some families and the escape of others 
is not so much in the vital resistance of 
the several members, but the neglect in 
the individual of personal hygiene. This 
is true of all diseases, as well as of hay- 
fever. It is true that children, and young 
people in general, are more likely to con- 
tract catarrhal colds if they are burdened 
with adenoids or hypertrophied tonsils — 
diseased by repeated former attacks. I 
believe that the acute infectious diseases, 
particularly in children, may be lessened 

[168] 



FORMS OF TREATMENT 

by most thorough and repeated steriliza- 
tion of the nasopharynx, and just as house 
epidemics are never excusable evils so I 
claim the same to be eventually true of 
hay-fever. 

The important result to be obtained 
through local treatment is the prevention 
of the paroxysms, and, ultimately, the re- 
moval of the recurring habit periods. The 
destruction, if possible, of the recurring 
habit. Years ago I was led to treat my 
hay-fever patients by cleansing the naso- 
pharynx with an atomizer containing a 
warm solution of boric acid (ten grains to 
an ounce of water) or D obeli's solution, 
after which I carefully wiped the mucous 
membrane and applied menthol and cam- 
phor and liquid cosmoline freely to the 
parts. This procedure afforded consider- 
able temporary relief in a large number of 
cases when there was present simply 

[169] 



HAY-FEVER 

turgescence of the whole naso-pharynx. 

1$. Sodium bicarbonate, 

Sodium borate a& giss 

Carbolic acid 5 j- 

Glycerin 5ij. 

Rose water (25 per cent.) q. s. O j. 

Sig. — Teaspoonful to one ounce of warm water. 

This I thoroughly use in both nostrils, 
first by means of an atomizer, after which, 
with a curved applicator or cotton-carrier, 
I very carefully swab the whole naso- 
pharynx. I scrub most carefully and 
gently every portion of the mucous mem- 
brane, being sure to reach between the tur- 
binated bones and all around and over 
every slight prominence. I then as care- 
fully dry the membrane with clean cotton, 
and use freely a mild solution of menthol 
and camphor in albolin, in proportion as 
follows : 

1$. Menthol gr. v. 

Pulverized camphor gr. v. 

Albolin 5 ij- 

[170] 



FORMS OF TREATMENT 

I loosely ping the nose for a few minutes 
to retain the oily application. It is impor- 
tant to sterilize most thoroughly the sen- 
sitive areas of the nose, as we are unable 
to determine whether one or more may be 
affected, and by this mild yet thorough 
treatment we cleanse effectually the whole 
nasal chamber. 

This treatment was so extremely simple 
that for a long time I doubted its real 
value, but as so many sufferers have ex- 
prest their relief, and were willing and 
anxious for me to continue the applica- 
tions, I have concluded to offer my methods 
in full confidence of their usefulness, with 
a warning that for successful treatment 
the instructions for cleansing and scrub- 
bing must be followed in careful detail. 
Good results need not be expected by 
simple irrigation and swabbing — the whole 
nasal mucous membrane must be tlior- 

[171] 



HAY-FEVER 

oughly washed and gently scrubbed be- 
fore the oily applications are used. 

This internasal treatment should com- 
mence four weeks before the expected on- 
set of the paroxysm, and should be done 
daily, if possible. 

I have found many persons who will not 
tolerate the use of carbolic acid, even in 
so mild a solution as that given above, the 
weakest solution frequently causing a se- 
vere urticaria. 

When various idiosyncrasies to carbolic; 
acid forbid its use, I select as the second 
best detergent hydrogen dioxid, and com- 
mence with the following mixture : 

3$. Hydrogen dioxid, 

Glycerin aa §ss. 

Distilled water q. s. giv. 

With this I spray the nose most thor- 
oughly, following it up with plain warm 
normal salt to remove the accumulation of 

[172] 



FORMS OF TREATMENT 

foam that will necessarily collect in the 
nasal spaces. A few days, or better, one 
week prior to the date of the onset, I in- 
crease the strength of the hydrogen-dioxid 
solution, using something like the follow- 
ing: 

1$. Hydrogen dioxid gij. 

Glycerin, 

Distilled water a5 §ij. 

This nrast be removed also by means of 
the normal salt, as already mentioned. In 
a number of cases I have found glycerin 
objectionable as a vehicle, producing an 
irritation of much annoyance. In such 
cases I omit the glycerin and substitute 
normal salt. In a few cases the hydrogen 
dioxid produced an inflammation of the 
mucous membrane that would require its 
dilution. We find many personal idiosyn- 
crasies in a large number of hay-fever suf- 
ferers that one might go on indefinitely 
[ 173 ] 



HAY-FEVER 

with modifications of treatment, but, as in 
general practise, it is our aim to treat the 
individual primarily, and we can not dog- 
matically hold fast to any special drugs or 
formula. 

In the few obstinate cases in which ster- 
ilization seems to provoke trouble, and the 
slightest manipulations of the nose and 
throat precipitate violent paroxysms, I use 
on the nasal mucous membrane the follow- 
ing powder : 

1$. Morphin. sulf gr. ij. 

Boracic acid 5ss. 

Powdered camphor gr. x. 

Powdered starch 5iv. 

Sig. — To be used as a snuff frequently. 

If patients object to the use of the snuff, 

and occasionally we will find some who 

will do so for cosmetic reasons, I prescribe 

the following, to be taken internally: 

IJ. Tablet Suprarenal Ex gr. v. 

Sig.— One every three or four hours. 
[174] 



FORMS OF TREATMENT 

Many physicians claim that relief can 
not be afforded to hay-fever patients with- 
out using cocain or eucain at some time 
during the management of troublesome 
cases. It is very exceptionally that I re- 
sort to either; possibly an unusual case 
will require one or more applications to 
control a local storm, yet the majority of 
patients never receive cocain from my 
hand. 

In severe cases that came under my care 
after the disease had been well established, 
when I had no chance to conduct a prelim- 
inary course of benumbing, I have been 
forced to prescribe something like the fol- 
lowing : 

Menthol gr. viij. 

Boric acid gr. xxx. 

Albolin 5 ij . 

Solution of Eucain "B" (4 per cent.) . gij. 

This is applied carefully and thoroughly 

on cotton applicators to the mucous mem- 

[175] 



HAT-FEYER 

brane of the naso-pharynx. It may con- 
trol the attacks, and it frequently aborts 
them and keeps the patient decidedly com- 
fortable. I have found the direct appli- 
cation of the remedy more satisfactory 
than the atomizer. In some cases, for a 
few days, this application must be made 
two or three times daily. 

H. L. Swain recommends the local use 
of the aqueous extract of the suprarenal 
glands in certain chronic conditions of the 
hay-fever type, as a powerful local vaso- 
constrictor and contractor of erectile tis- 
sue. The local effect can apparently be 
obtained any number of times without en- 
tailing a vicious habit, such as might re- 
sult from cocain. Ingals and Ohls report 
that they have obtained much relief in 
these cases by the use of an extract of 
suprarenal capsule prepared as follows: 
Adrenals (Armour's), §j; boric acid, gr. 

[176] 



FORMS OF TREATMENT 

xvj; cinnamon water, 3iv; hot camphor 
water, 3J; hot distilled water, enough to 
make §ij. Mix, macerate for four hours, 
and filter. This solution remains stable 
for several weeks. It is used as a spray 
four or five times a day. I have not had 
occasion to resort to the local application 
of this substance, but I have had one pa- 
tient who was distinctly benefited by in- 
ternal administration in doses of gr. y± to 
gr. j, as often as four times a day. He was 
a catarrhal young man of neurotic tem- 
perament, who came to me during the first 
week of his attack, and who objected to the 
usual routine sterilization of the naso- 
pharynx. 1 

The formula : 

Adrenal chlorid . . . 5 ij* 

Normal salt sol q. s. 5 j. 

is more elegant and convenient. 

1 Personally the use of the suprarenal extract has 
been of little value owing to the violent sneezing 
provoked. 

[177] 



HAY-FEVER 

3. As to Diet, Exercise and Rest 
In old cases, when the nerve-habit has 
long been formed, treatment should com- 
mence at least two or, better, three weeks 
before the anticipated recurrence of the 
paroxysms. All bodily irregularities must 
be corrected and tendencies to constipation 
or dyspepsia removed. Amylaceous indi- 
gestion should be corrected by the exclu- 
sion from the dietary of too starchy foods. 
For the elimination of excessive uric acid, 
or other waste products, and to relieve 
constipation, the systematic administra- 
tion, morning and night, of sodium phos- 
phate is invaluable. If the appetite is 
not good, the regular use of the tincture 
of nux vomica, ten to twenty drops three 
times a day, is strongly indicated. In 
anemic cases pills of carbonate of iron or, 
probably still better, the pills of valerian- 
ate of quinin, iron, and zinc are necessary. 

[178] 



FORMS OF TREATMENT 

In nervous cases with anemia, valerianate 
of zinc, one grain with two grains of the 
compound asafetida pill, two or three 
times a day (after Morell Mackenzie), will 
be found valuable. Careful diet, a tran- 
quil mind, and moderate exercise are es- 
sential. Outdoor exercise, with a daily 
tepid bath followed by vigorous friction of 
the whole body, will help to eliminate waste 
material. The patient should not unneces- 
sarily expose himself to direct rays of the 
sun, as they are calculated to excite intense 
reflex irritation of the sensitive nerve cen- 
ters. Much trouble may be averted by the 
use of a sunshade or umbrella and by the 
avoidance of exercise in the sun. 

It must be understood that with the gen- 
eral hygienic and constitutional treatment 
the course of local prophylaxis by daily 
sterilization is most necessary. 

The treatment of neurasthenic cases, or 

[179] 



HAY-FEVER 

those in which a decided derangement of 
the general system as well as of the ner- 
vous energy exists prior to the attack, re- 
quires the greatest tact and skill. If there 
is little local catarrhal disturbance there 
will be great difficulty in combating the 
disease in the face of the deprest vitality 
and lessened nervous resistance. In such 
cases I place the patients upon a diet, 
somewhat like that in the appended list, 
and urge strict adherence to it. After ob- 
taining careful urinary analysis and other 
clinical data, I often further specialize in 
the diet, or I may increase the variety ac- 
cording to the needs of the individual. In 
these cases I always urge the drinking 
of large quantities of water, unless there 
is some strong contraindication. Neuras- 
thenics will often avoid water between 
meals. I at once order systematic mas- 
sage. If the patient does not care for a 

[180] 



FORMS OF TREATMENT 

massenr, I order a daily tepid bath of a 
temperature between 80° and 85° F., with 
a coarse towel rubbing, followed by a 
douche of cold water along the spine. This 
should be continued for at least two weeks 
prior to the onset of the paroxysms. 

Rest for the overtaxed function is im- 
peratively demanded. Unfortunately, this 
is easier prescribed than carried out. In 
wealthy patients the Weir-Mitchell rest- 
cure often gives brilliant results. In other 
cases a change of scene and a temporary 
rest from business or society may be ac- 
cepted when the sanitarium would be out 
of the question. Quiet resorts on the sea- 
coast or in the mountains are desirable. 
Nothing is better than two or three weeks 
on the ocean. A compromise may be ob- 
tained by having the patient give up a por- 
tion of the daily duties and go to bed 
earlier at night. The patients should not 

[181] 



HAY-FEVER 

be allowed to discuss their ailments too 
freely. Horseback riding, bicycling, row- 
ing, and walking — in fact, any outdoor di- 
version not too violent — are to be recom- 
mended. 

If the patient suffers from insomnia, 
careful administration of a hypnotic may 
help to reestablish the sleep-habit. At first 
give a warm bath, and a glass of warm 
milk or malted milk before retiring. If 
this and other similar measures do not 
avail, five grains of Veronal capsule may 
be given one hour before going to bed. If 
the patient is accustomed to wake after 
a short sleep, the Veronal should be given 
at bedtime. Full amounts of sleep are 
necessary to neurasthenics. Depressants, 
such as the bromids, chloral, and the opi- 
ates should be avoided. Any coexistent 
gastric or cardiac trouble must be care- 
fully treated, and the bowels kept open 
regularly. 

[182] 



FORMS OF TREATMENT 

The diet that I find most desirable to 
follow, generally speaking, is that which 
is applicable to the gouty or uric acid 
diathesis. 

General Rules. — The diet should be lib- 
eral, but not stimulating, with moderation 
in animal foods, and very little of foods 
having a tendency to produce acids in the 
system, such as starches, sugars, fats, and 
fermented liquors. Patients may take 
soups — clear or vegetable — and weak beef- 
tea or broths. 

Fish. — Fresh fish and raw oysters. 

Meats. — To be taken once a day only — 
mutton, chicken, underdone roast, sweet- 
bread. 

Eggs. — Moderation. White of eggs, 
raw, or shirred in drinks, such as lemon- 
ade, occasionally. 

Farinaceous. — In small quantities. 
Toast, stale bread, bread from whole 

[183] 



HAY-FEVER 

wheat, rye bread, milk-toast, rice, crackers. 

Vegetables. — Fresh, green varieties 
preferable ; celery, lettuce, watercress, 
cucumbers, onions, cabbage, salads, spar- 
ingly of baked potatoes, young peas, string 
beans, and spinach. 

Desserts. — Oranges, lemons, apples, 
apricots, pears, peaches, cherries, blanc- 
mange (not after meals, however), stewed 
fruit. 

Beverages. — "Water, plentifully, espe- 
cially before meals ; plain soda, milk, but- 
termilk, weak tea or coffee (without su- 
gar), toast-water, lemonade. Mineral 
waters, such as Saratoga Vichy, Berkely 
(Hot Springs), Lithia Water, Carlsbad, 
and Crab Orchard. 

Stimulants. — Light Hock; Bordeaux in 

small quantities and well diluted. 

Articles Forbidden. — Patients must 
avoid rich soups, hard-boiled eggs, frred 

[184] 



FORMS OF TREATMENT 

and made dishes of all kinds, entrees, 
pickles, spices, veal, pork, duck, goose, sal- 
mon, lobster, crab; preserved, dried, and 
salted meats; salt fish, pickled pork, as- 
paragus, old peas, beans, tomatoes, muslv 
rooms, truffles, dried fruit, preserves, pies, 
pastry, rich puddings, patties, new bread, 
cheese, sweets, malts, sweet wines, straw- 
berries, rhubarb, cider, fermented drinks, 
beer. 

4. When Asthma Occurs as a Sequel 

About five to ten per cent, of my whole 
number of hay-fever patients have suf- 
fered more or less from asthma. Asthma, 
as a sequel in these cases, manifests itself 
about the end of one week or ten days after 
the expected paroxysms of hay-fever, and 
is induced usually by some undue exposure 
or a damp or rainy day. My asthmatic 
patients, I find, were among those irregu- 

[185] 



HAY-FEVEK 

lar in treatment, or those who had first 
called late in the disease. In these cases 
much mucus had accumulated in the lar- 
ger tubes. If I can not clear the bronchial 
tubes by an emetic dose of ipecac, I pre- 
scribe somewhat as follows: 

Potassium iodid 5ss 

Ammonium muriate 5ss 

Sirup of Yerba Santa g j. 

A teaspoonful administered every two 
hours generally brings relief. A number 
of asthmatic patients require a solution of 
nitroglycerin, one per cent. Of this, one 
drop every two hours for two or three 
days is given. Occasionally it seems im- 
perative to give morphin. Some of my 
asthmatics have informed me that they can 
bring about immediate relief by plunging 
both hands in hot water and taking a drink 
of whiskey, followed by a large draft of 
hot water. It is possible for some persons 

[ 186 ] 



FOEMS OF TREATMENT 

to voluntarily combat their asthmatic at- 
tacks, and for this reason they should be 
encouraged to practise certain breathing 
exercises until they can in a measure con- 
trol their respiratory apparatus. Asth- 
matics usually have, however, a preexist- 
ent catarrhal state of the bronchial tubes, 
which exhibit marked vasomotor changes 
on slight irritation. If I see these patients 
early, I prescribe five-minim capsules of 
the oil of sandalwood four times a day, or 
the compound salol capsule, and by the 
time their period arrives, the bronchitis 
is fairly well cleared up. 

The inhalation of the fumes of burning 
niter-paper or specially prepared powders, 
or of cigarets, gives relief in many cases. 
The powders used at the Brompton Hos- 
pital by Sidney Martin contain one part 
each of anise and niter, two parts of stra- 
monium leaves, and five grains of tobacco 

[187] 



HAY-FEVER 

to the ounce ; one teaspoonf ul is to be burnt 
on a plate and the fumes inhaled. A pill 
containing y± of a grain of morphin, with 
1/200 of a grain of atropin sulfate, given 
at bedtime, is sometimes useful in connec- 
tion with the inhalations. Extract of stra- 
monium (1-16 of a grain) may be substi- 
tuted for the atropin. 

S. Solis-Cohen has used successfully the 
following formula : 

1$. Morphin sulf gr. \-\. 

Strychnin sulf gr. \-^t$. 

Hyoscin hydrobrom . . . . gr. -^. M. 
Sig. — Give hypodermically at bedtime. 

The following may be administered at 
night : 

1$. Camphor gr. ss 

Dover's powder gr. vj. 

Make four capsules. 

Sig. — Take one on retiring. 

Van Sweringen calls attention to a line 
of treatment in a very obstinate case of 

[188] 



FORMS OF TREATMENT 

bronchial asthma that was attended by re- 
markable results. The attack had lasted 
for two weeks, during which time all the 
antispasmodics had in turn been ex- 
hausted, and the patient had secured but a 
period of two hours' freedom at any one 
time. Finally, based on the theory that if 
asthma was a reflex it must be under the 
control of Setschenow's inhibitory center, 
and that anything that would stimulate the 
inhibitory center would lessen the reflex- 
spasm, quinin and strychnin were given, 
with excellent results. The dose of the 
quinin was seven grains. The extract of 
nux vomica was given in %-grain doses, 
and to this was added % of a grain of co- 
dein sulfate. In the interval the iodids 
were continued. 

However, the use of sedatives and in- 
halations must be limited, especially in the 
milder and uncomplicated forms of asth- 

[189] 



HAY-FEVER 

ma, while efforts to benefit the patient's 
general condition are strongly indicated. 
Diet is an important part of the treatment 
of many cases. Not all cases of asthma are 
due to uricacidemia, but nearly all cases 
are benefited by attention to the diet and 
elimination of excess uric acid. 

Of remedies that may be continuously 
administered to patients who have fre- 
quently recurring attacks, two are most 
constantly used — namely, iodid of potas- 
sium and arsenic. The iodid may be most 
conveniently given with stramonium, as in 
the mixture devised by Martin, which con- 
sists of 14 of a grain of extract of stramo- 
nium, two grains of extract of licorice, 
three grains of iodid of potassium, and five 
minims of chloric ether. This mixture may 
be given two or three times daily in cases 
of asthma. It possesses two disadvan- 
tages, however. The stramonium leads, in 

[190] 



FORMS OF TREATMENT 

some cases, to paralysis of accommoda- 
tion, but by diminishing the dose, the pa- 
tient soon ceases to experience discom- 
fort from the remedy. If given alone, the 
iodid must be administered in five-grain 
doses two or three times daily, the medicine 
being discontinued from time to time. Ar- 
senic by itself, in doses of three minims of 
the liquor arsenicalis, is a useful remedy 
for continuous administration in asthma, 
and it may be combined with potassium 
iodid (three to five grains) in a mixture. 
Hydrotherapeutic treatment is of use in 
some cases of asthma. The patient should 
be accustomed to gradually colder baths of 
short duration with douches. 

5. The Use of Serums — Dunbar's 
Serum 

The wide recognition of the serum treat- 
ment of hay-fever by Dunbar, of Ham- 

[191] 



HAY-FEVEK 

burg, Germany, requires me to quote suffi- 
cient of his writings that my readers may 
appreciate the value as well as the limita- 
tions of his work. To very briefly sum- 
marize: Dunbar has prepared hay-fever 
antitoxin by inoculation of horses with 
the toxins derived from the albuminoid 
body found in the starch particles of the 
pollen. The serum obtained from the 
horse is dispensed either in a liquid or 
dry form, and is designed to be applied to 
the mucous membrane of the nose and the 
eye when required. 

His serum has been named Pollantin, 
and two forms are on the market, one pre- 
pared from rye pollen, especially used for 
spring and summer hay-fever, or "rose- 
cold," and the other, prepared from rag- 
weed pollen, designed as a remedy for hay- 
fever occurring in the late summer and 
fall. Dunbar thinks that hay-fever is the 

[192] 



FORMS OF TREATMENT 

result of a specific poison found in pollens 
and is an albuminoid body — and his anti- 
toxin is intended to inhibit, or immunize 
patients against the pollen toxins if used 
previous to the hay-fever season. Its use 
is also to palliate the symptoms in cases 
where the disorder has already made its 
appearance. Pollantin produces a sensa- 
tion of relief and cool comfort when ap- 
plied to the inflamed mucous membrane of 
the nose or eye. This comfort remains for 
some time, but the relief is variable. 

In 1902, Prof, W. P. Dunbar published, 1 
as an appendix to a presentation of the 
history of our knowledge of hay- fever, the 
opinion, based on experiment, that hay- 
fever is a disease caused by a poison de- 
rived from plants. These toxic substances 
are found in the dust of the blossoms of 

1 Zur Ursache u. spezif . Heilung d. Heufiebers. 
Verlag Oldenbourg, Munchen, 1903. 

[193 



HAY-FEVER 

certain plants. They are present in the 
albumin of the pollen and are septic in 
nature. According to this theory, it would 
be possible, by means of the isolated toxic 
albnmin of the pollen, to determine whether 
or not a given disease was hay-fever. It 
was also hinted, and in a publication that 
shortly followed, 1 positively asserted, that 
it was possible to produce a specific anti- 
toxin by inoculating animals, e.g., rabbits 
or horses, with the albumin of the pollen. 
It was possible with this antitoxin to neu- 
tralize the poison of the pollen in vitro so 
that the latter would no longer cause 
symptoms in hay-fever patients. It was 
also claimed that symptoms that had al- 
ready set in could be overcome by the use 
of the specific antitoxin. 
By means of this timely use of the anti- 

*Zur Frage betreffend d. Aetiologie u. spezif. 
Therapie d. Heufiebers. Berl. klin. Woch., 1903, No. 
24—26. 

[194] 



FORMS OF TREATMENT 

toxin the outbreak of the hay-fever symp- 
toms should be prevented. As a result of 
further investigation he was later able to 
prove definitely 1 that by the proper use of 
the antitoxin it would be possible to rid 
patients of their disposition to hay-fever, 
and to immunize them so they could dis- 
pense with the use of the antitoxin or any 
other therapeutic agent without having to 
fear further attacks. 

Th. Albrecht, the secretary of the Ger- 
man Hay-Fever Association, designated 
the appearance of my first article as a 
turning-point in the history of hay-fever. 
Other colleagues viewed the results of 
Professor Dunbar 's comprehensive work 
with less favor. There were indeed those 
who claimed that he had added nothing 
new to the subject. The opinions ex- 

1 Zur Ursache u. spezif. Heilung d. Heufiebers II. 
Deutsch. med Woch., 1911, No. 13. 

[195] 



HAY-FEVER 

prest by the laity were also widely dif- 
ferent in character. Some were unable to 
express their thanks in terms sufficiently 
strong, others claimed that the specific 
treatment suggested by him was absolutely 
worthless. An American correspondent 
wrote to him: "Your stuff is not worth a 
tinker's dam." In the face of such diver- 
gent opinions it seems worth while to cast 
a glance backward over the decade that 
has passed, to determine what assertions 
were right and what opinions were incor- 
rect. 

Whether we are right in looking upon 
hay-fever as a product of our modern cul- 
ture, appeared to Professor Dunbar to- 
day, even more than it did ten years ago, 
an open question. In the last ten years 
there has been much published concerning 
hay-fever, not only in the leading journals, 
but also in the lay journals. 

[196] 



FORMS OF TREATMENT 

In so far as the latter deals with his 
work, they had not had his cooperation, 
nor had they consulted his wishes. There 
are to^ay many hay-fever patients who 
are absolutely in the dark as to the nature 
of their disease. Even in Hamburg, after 
a scientific exhibition at which his hay- 
fever material was shown, many adults 
came to him with the request that he 
should determine whether or not they had 
hay-fever. He was even more surprized 
to learn that there are to-day physicians 
who either deny the existence of hay-fever 
or know nothing about it. In view of this 
obtuseness it seemed to him very bold to 
say that two hundred and fifty years ago 
there was no hay-fever, simply because we 
have no authentic and convincing records 
from that time. The disease may have 
been very widespread then. There was 
missing perhaps only the man to notice the 

[197] 



HAY-FEVER 

periodicity of the disease, its dependence 
upon the seasons of the year, and to cor- 
rectly correlate the facts and draw proper 
conclusions. 

Until ten years before Dr. Dunbar says 
no one had been able to offer a clear and 
convincing explanation of the cause or 
nature of hay-fever. This is clear from 
a perusal of the literature up to that time. 

Dr. Dunbar, himself a sufferer from hay- 
fever, had the opportunity during many 
years to test the merits of the various 
hypotheses concerning the cause of the 
disease. He finally came to the conclusion 
that only the pollen theory could be right. 
In his monograph concerning hay-fever, 
which thus far I have given in his own lan- 
guage as above, he described the observa- 
tions which forced him to accept this ex- 
planation. For many years the attempt to 
definitely prove the theory met with an ob- 
[ 198 ] 



FORMS OF TREATMENT 

stacle which seemed insuperable, viz., the 
impossibility of getting pollen in a pure 
state. In view of the extremely simple 
method of doing this, this fact appeared 
to him to-day a remarkable one. He felt 
constrained to offer the following ex- 
planation : 

"Year after year I consulted with bot- 
anists as to the best method of getting pol- 
len in large quantities. Various methods 
were suggested to me, among others that 
of spreading large cloths over the mead- 
ows. I also sucked up into bottles large 
quantities of air in the attempt to get pol- 
len, and attempted many other things. 
None of these methods met with more than 
moderate success, until finally I hit upon 
the simple procedure of shaking blooming 
plants, for instance stocks of wheat, and 
catching the dust that was shaken out. I 
succeeded better later by taking the ears 

[199] 



HAY-FEVER 

shortly before they began to bloom and 
putting the stocks in water in a warm 
place. In this way I was soon able to 
gather pollen in large quantities, and, 
more important still, to isolate the pollen 
grains of different plants, free from all 
contaminations, including micro-organ- 
isms. 

" After having obtained in this way the 
pollen of rye, wheat and ray-grass pollen 
(Lolium perenne), I could at once begin 
to attempt the settlement of important 
questions. A minimal amount of the plant 
dust when introduced into my conjunc- 
tival sac, or my nasal passage, caused in a 
very short time most pronounced hay- fever 
symptoms. The same experiment on my 
laboratory assistant, who did not have hay- 
fever, had no effect at all. Within a few 
days I extended the scope of my experi- 
ments so as to include two hay-fever pa- 

[ 200] 



FORMS OF TREATMENT 

tients, who happened to be working in our 
institution, as well as three other assist- 
ants who did not have hay-fever. The 
result was always the same. The hay-fever 
patients reacted just as I did. Those who 
had no hay-fever and served as controls 
were not at all affected by the introduction 
of the pollen. These experiments were 
repeated later on very many patients and 
people without hay-fever, invariably with 
the same results. 

"The next important point that sug- 
gested itself to me was to determine 
whether or not this toxin was active at 
other times of the year than during the 
hay-fever period. Formerly it had been 
urged against the pollen theory that with 
the same pollen which had been active dur- 
ing the hay-fever period, no results could 
be achieved at other times of the year. 
Thus, for instance, Sticker was of the 

[201] 



HAY-FEVER 

opinion that Woodward had proved that 
pollen was inactive except during the hay- 
fever period. He therefore was forced to 
come to the conclusion that for the pro- 
duction of an attack there was necessary 
the disposition on the part of the indi- 
vidual and the season of the year. The 
nature of the action of the season of the 
year was explained by some authors as a 
sort of an "Unstimmung," a sort of spring 
revolution. ,This explanation appeared to 
me very doubtful, because of the fact that 
this process occurs in European patients 
in springtime ; in most American patients, 
however, in the fall. 

"My experiments on this subject re- 
sulted as follows: Pollen which had been 
carefully dried soon after gathering was 
active later at any time of the year. 
Pollen, however, which I enclosed in bot- 
tles in its fresh condition underwent cer- 
[ 202 ] 



FORMS OF TREATMENT 

tain changes, characterized especially by 
the formation of a liquid. 

"Pollen which had been spoiled in this 
way proved later to be inactive. I might 
add here that these observations explained 
the occurrence of sporadic cases of hay- 
fever in the winter time. Pollen which has 
found its way into a dry room can remain 
active until the winter season — indeed, for 
many years, as I have shown. One blossom 
which has remained for eleven years in the 
herbarium retained an undiminished ac- 
tivity. Pollen which, on the other hand, 
falls to the ground in the open air, is de- 
stroyed by the first following rain. The 
fact that the pollen is carried down out of 
the air by the rain clearly explains further 
the remissions on certain days which had 
hitherto been so difficult to understand. 
By means of the isolated pollen I had then 
met those requirements in my attempts at 

[ 203 ] 



HAY-FEVER 

an etiologic explanation which I myself 
have considered necessary. The suspected 
agent, free from all impurities, when ap- 
plied to a hay-fever patient, must produce 
hay-fever invariably, regardless of the 
season of the year. The same agent ap- 
plied to a normal person must have no 
effect. These requirements had, I say, 
been met by experiment. 

"The grass pollen is so small that a 
single one can not be seen with the naked 
eye, yet its structure and chemical compo- 
sition are very complicated. Many pollen 
grains are covered with hair-like prickles. 
Adherents of the pollen theory formerly 
believed that hay-fever was due to these 
prickles. They asserted that hay-fever 
patients were extremely sensitive to the 
mechanical stimulus of the prickles, and 
that normal individuals were resistant to 
their action. It is true that some of the 

[204] 



FORMS OF TREATMENT 

pollen, which we formerly looked upon as 
the cause of hay-fever, had an uneven, 
prickly surface. Some of the first adher- 
ents of the pollen theory believe that those 
pollen especially were active whose blos- 
soms had an intense odor. The disease 
was accordingly at that time widely called 
rose-fever, linden-fever, and so forth, in- 
stead of hay-fever. I was able to show 
that those pollen which most often cause 
hay-fever have a smooth surface. This is 
true of all grass pollen, of which I have 
examined thirty-two varieties. These have 
also no odor. The blossoming of the rose 
and of linden occurs at the same time as 
that of the grasses. In 1902 I was able to 
completely overthrow the belief in the 
activity of the linden. It happened that in 
that year the blossoming of the linden 
was delayed from three to seven weeks in 

our vicinity, that of the grasses occurring 
[205 ] 



HAY-FEVER 

at the regular time. The season for hay- 
fever was probably over at the time that 
the blossoming of the linden was at its 
height, and hay-fever patients were able 
to enjoy the odor of the linden without any 
ill effects. I can well understand the te- 
nacity with which hay-fever patients cling 
to the belief that the dust of the rose and 
linden causes their symptoms. I myself 
banned from my home every rose and 
other odorous blossom during the hay- 
fever period, and felt certain that my suf- 
fering was thereby diminished. The relief 
was not an imaginary one, but was due to 
the fact that at the same time I kept my 
windows carefully closed. 

"At about the time of the blossoming 
of the grasses, the pine (Pinus sylvestris) 
also begins to blossom and produces such 
a plentiful dust that thick clouds of it can 
at times be seen. This is called sulfur 

[ 206 ] 



FORMS OF TREATMENT 

rain. I proved, in spite of the opposition 
of many hay-fever patients, that the dust of 
this blossom was also of no consequence. 

"By such experiments as these and 
many others I was able to prove that only 
certain specific pollen could cause hay- 
fever. This was in direct opposition to 
Blackley's theory. Other pollen, includ- 
ing those possessing sharp prickles, were 
absolutely without effect. 

"The theory as to emanations, odors, 
ethereal oils, and so forth, had still to be 
considered. On opening a vessel that con- 
tains much grass pollen one gets an odor 
much like that of honey, which proved to 
be without effect on hay-fever patients. 
The odor of the linden, as well as that of 
the harmless rose, was proved to be with- 
out effect. There was still to be considered 
the questions as to the action of the 
ethereal oils. An extract of the oily and 

[ 207 ] 



HAY-FEVER 

waxy portions of the pollen, when applied 
to the conjunctiva and nasal mucous mem- 
branes in small amounts, caused a burning 
sensation. This was quite different, how- 
ever, from the peculiar sensation experi- 
enced by hay-fever patients, which is so 
distinctive that nothing can stimulate it. 
These extracts had more effect on normal 
persons than they had on hay-fever pa- 
tients. The amount of these substances 
with which we come in contact in our 
ordinary walks is so small that they can 
surely not be responsible for any of our 
unpleasant sensations. 

6 ' Grass pollen is distinguished from that 
of other plants in a marked way by the 
small rods which it contains, which look 
just like bacteria. Patton, in 1877, had 
already called attention to these rods. He 
believed that after they left the pollen 
grains they possest a movement of their 

[208] 



FORMS OF TREATMENT 

own, and he drew the conclusion that they 
constituted the active principle of the 
pollen. He asserted that by reason of their 
inherent motility they found their way 
into the mucous membrane and the circula- 
tion and thus caused the symptoms of hay- 
fever. For a time, I also believed that 
these small rods played some part in the 
production of hay-fever. I did not know 
then that they were composed solely of 
starch, but thought they contained al- 
bumin. After I was able to get hold of 
great quantities of grass pollen I was able 
to isolate these rods by means of repeated 
centrifugation and washing. I was then 
able to prove that they were absolutely in- 
nocuous to hay-fever patients. 

u Asa result of certain observations, to 
which I shall refer later, I was soon forced 
to the conclusion that the active principle 
of the toxin of hay-fever is an albuminous 

[209 ] 



HAY-FEVER 

substance. The alcoholic precipitate from 
a saline extract of a comparatively small 
number of pollen grains had an intense 
action on hay-fever patients, but none 
on normal individuals. After I obtained 
large quantities of pollen I began my 
experiments with the isolated albumin. 
Against this method of procedure it was 
claimed that I had not been working with 
a true hay-fever toxin, but with a dena- 
tured poison. For this claim there is no 
evidence; the critics failed completely to 
show any proof for the correctness of their 
assertions. From a purely scientific view- 
point, it is certainly better to work with 
the isolated toxin than the whole pollen 
grain or an extract from them such as I 
used at first, before I realized that the 
toxicity was an attribute of the albumin 
alone. 
"Dr. 0. Kammann, who investigated 

[210] 



FORMS OF TREATMENT 

this matter at my request, 1 was able to 
prove that the albumin fraction contains 
the toxin and that the globulin fraction is 
entirely inactive. 

"Having determined that the albumin of 
the pollen is the specific cause of hay-fever, 
it was possible now to carry out my experi- 
ments along quantitative lines. It is pos- 
sible to extract the albumin from the pollen 
by means of saline solutions of proper 
strength and then to precipitate it with 
alcohol or to obtain it by dialysis, and then 
dry it. In this condition it retains its ac- 
tivity for many years. 

"The experiments which I had done up 
to this time on hay-fever patients had not 
conformed to the natural process. In 
order to conform to these more closely I 
performed the following experiment: A 

1 Kammann: Zur Kenntnis d. Eoggen-Pollens u. des 
darin enthaltenen Heufiebergiftes. Beitrage z. Chem. 
Physiol, u. Pathol., 1904. Bd. V, Heft. 7-8, S. 346. 

[211] 



HAY-FEVEK 

hay-fever patient and a normal individual 
took their places in a large glass cabinet 
in which rye pollen had been distributed. 
The hay-fever patient took sick, the other 
remained well. It was not determined by 
this experiment how mnch of the pollen 
had been taken up by the hay-fever patient. 
The question as to whether or not enough, 
pollen was present in the air during the 
hay-fever season to cause the symptoms 
had not been satisfactorily settled. Black- 
ley (vide supra) had already made at- 
tempts to settle this question by means 
of a method worked out by Phoebus. He 
had carefully counted at different periods 
of the years the pollen which gathered on 
glass plates, whose surface had been cov- 
ered with glycerin. My co-workers, es- 
pecially Lief mann, 1 found that in the heart 

1 Lief mann : Ein Beitrag zur Frage naeh d. aetiologi- 
schen Bedeutung gewisser Pflanzen f pollenkoerner f uer 
d. Heufieber. Zeitschr. f. Hyg. u. Infectionskrank- 
neiten, 1904, Bd. 47, p. 153. 

[212] 



FORMS OF TREATMENT 

of Hamburg, while hay- fever was at its 
height, 250 pollen grains accumulated on 
a surface of one square centimeter during 
twenty-four hours, i.e., 25,000 to the square 
meter. It was established that with the 
first appearance of the pollen in the air 
the patient began to complain of an itch- 
ing at the inner canthus of the eye; his 
suffering became more intense in direct 
proportion to the quantity of pollen in the 
air. On rainy days no pollen accumulated 
on the glass plates, altho they were pro- 
tected from the rain. Early in June the 
pollen of the grasses far exceeded those 
of other plants in numbers, and from about 
the third week in July grew gradually less, 
so that at the end of July, or the beginning 
of August, only a few stray grains were 
found. Thus can be explained the period- 
icity of the course of hay-fever and also 
the occurrence of sporadic cases after the 

[213] 



HAY-FEVER 

hay-fever season is over. There was still 
no certain method of predicting quanti- 
tatively the action of the pollen. Dr. 0. 
Kammann had shown that the organic 
portion of the pollen of the grasses is 
abont 40 per cent, albumin. He had shown 
further that about 20,000,000 rye pollen 
weighed one gram. By means of these 
figures we could compute the amount of 
toxin in a single pollen. By means of a 
solution of known strength of the poison- 
ous albumin of the pollen, it could be deter- 
mined how many pollen grains were neces- 
sary in any given case to produce mild, 
moderately severe, or severe symptoms. It 
was evident that different patients were 
susceptible in varying degrees. A concen- 
trated solution introduced into the conjunc- 
tiva or nose of a normal individual causes 
no symptoms. The majority of hay-fever 
patients were stimulated by one drop (1-20 

[214] 



FORMS OF TREATMENT 

to 1-30 cm.) of a solution of 1 to 20,000 or 
1 to 30,000. There were patients, however, 
who responded to one drop of a solution 
diluted a million times, the equivalent of 
the amount of albumin contained in one 
to three pollen grains. 

"Liefmann constructed an aeroscope 
by means of which he was able to de- 
termine how much pollen was taken in with 
each breath. In the neighborhood of a 
field of rye one inhales with each breath 
two or three pollen grains; in the middle 
of a large city he found that in every cubic 
meter of air there were about three hun- 
dred and eight. 

"Thus in this way questions as to the 
quantitative relationship of the pollen to 
the attack were satisfactorily answered. 
By means of these experiments it had been 
plainly shown that the albumin of the 
pollen of certain plants, especially that of 

[215 ] 



HAY-FEVER 

all grasses, is to be looked upon as the 
active cause of hay-fever. With my co- 
workers I examined the pollen of 106 
plants, and found them all without any 
action, altho I had examined such pollen 
which had been considered capable of 
producing hay-fever. In addition to the 
pollen, I had been informed that in China 
at the time of the blossoming of Ligustrum 
vulgare a disease very much like hay- fever 
was prevalent. I examined the pollen of 
this plant and found it active. In South- 
west Africa, when the grasses blossom, 
conditions like hay-fever prevail, es- 
pecially among the half-breeds. One 
European had to forsake Africa at this 
time on account of his intense suffering. 
In Europe he remained perfectly well. On 
examination it was found that he did not 
react to the grass pollen. In Africa, how- 
ever, at this time, the acacia blossom and 

[216] 



FORMS OF TREATMENT 

it has been looked upon as the cause of the 
condition. This patient was unaffected 
by the pollen of two different species of 
acacia. I am in hopes that experiments 
which we have since then set on foot will 
explain this disease to us. In addition to 
the thirty varieties of graminacese and 
cyperacese, I have found the pollen of 
the following plants active: swamp-pink 
(Lonicera caprifolium) , lily-of-the-valley 
( Convallaria majalis ) , hairy Solomon's 
seal {Polygonatum rnultiforwn), Oeno- 
thera biennis, rape (Brassica napus), and 
spinach (Spinacia oleracea). 

"Of special importance is the autumnal 
catarrh, which occurs in the United States 
of America, beginning early in September 
and lasting about six weeks. This autum- 
nal catarrh is much more common in the 
United States than the vernal catarrh. I 
have had the opportunity of examining a 

[217] 



HAY-FEVER 

large number of American hay-fever pa- 
tients, and was able to establish the fact 
that those patients who only suffer in the 
fall do not react at all to the albumin of 
the grass pollen. They do react, however, 
regularly to the albumin of the pollen of 
goldenrod (Solidago) and of ragweed 
(Ambrosia). I have examined a large 
number of species of both these plants and 
they were all active. These patients also 
react to the pollen of the chrysanthemum 
and the other asters. Those American pa- 
tients who suffer only from spring catarrh, 
not from the autumnal type, react only to 
the grass pollen, not to that of the golden- 
rod or the ragweed. A third group of 
patients suffer from about the middle of 
May until early in November with a hay- 
fever-like affection. These unfortunates 
react both to the grass pollen and to the 
active agent of the autumnal catarrh. 

[218] 



FORMS OF TREATMENT 

Goldenrod and ragweed are very wide- 
spread in the United States. They are 
found not only on meadows, fields, roads 
and along edges of woods, but grow in the 
midst of cities in neglected places. In 
Europe they do not occur naturally, indeed 
the goldenrod can with difficulty be made 
to blossom there. The pollen of goldenrod, 
however, is not scattered as easily as that 
of the ragweed. All attempts to grow 
ragweed in this country failed until 1911. 
In this year, which was extremely hot and 
dry, I succeeded for the first time. These 
facts serve as further important supports 
for the pollen theory. There were, how- 
ever, still many questions to be settled 
before all this mysterious phenomena 
which characterize hay-fever could be ex- 
plained. 

"One very important question, that of 
individual predisposition, I have only 

[219] 



HAY-FEVER 

lightly touched upon. It is clear that all 
people, including the inhabitants of large 
cities, are at certain times of the year ex- 
posed to the pollen of many plants, which 
settle on their skin, conjunctiva, are in- 
haled into the nose, and taken up into the 
mouth. By far the largest part of these 
individuals are unaffected by the pollen, 
only a very small percentage take sick. 
The poisonous albumin of the pollen is a 
substance, therefore, which is innocuous to 
most people, and is only active in those 
cases in which there is a special suscepti- 
bility. In other words, hay-fever requires 
an individual predisposition. This per- 
sonal predisposition is present for the well- 
known poisons of the pharmacopoeia, either 
not at all or at most in very slight degree. 
In the case of the infectious diseases it is 
much more evident. If, for instance, the 
cholera or typhoid bacillus is spread 

[ 220] 



FORMS OF TREATMENT 

through a city by means of the water sup- 
ply, only a small percentage of the inhabi- 
tants are unaffected. This can be ex- 
plained on the theory that the cholera 
organism does not find in most individuals 
those conditions which are necessary to its 
existence and growth. The fact that only 
about half of the cholera patients die 
can be explained by similar quantitative 
differences. I do not know of another 
instance of a substance absolutely in- 
active as far as a part of the popu- 
lation is concerned, but a very virulent 
poison for others. The individual pre- 
disposition in a case of hay-fever must 
be of a peculiar sort. It might be ex- 
plained that the hay-fever poison enters 
the circulation of some people (hay-fever 
patients) and not of others. That this is 
the case I could prove by the demonstra- 
tion of antibodies in the blood of the hay- 

[221] 



HAY-FEVEK 

fever patients. I shall return to this sub- 
ject later. Here it is sufficient to say that 
these specific substances could be found 
only at the close of the hay-fever period; 
six months later they had disappeared. In 
normal individuals they could at no time 
be demonstrated. The gradual disappear- 
ance of the immune bodies is easily ex- 
plained. We know from animal experi- 
ment that these substances appear a 
certain time after infection, gradually to 
disappear again. At first blush the dem- 
onstration of immune bodies in the blood 
of hay-fever patients would seem to be a 
sufficient explanation of the hay-fever pre- 
disposition. Close study makes this seem 
uncertain. 

On continuing the experiments I found 
that these immune bodies were not pres- 
ent in all patients, indeed, in the same pa- 
tient I could not find them in some cases 

[ 222 ] 



FORMS OF TREATMENT 

two years in succession. The following 
objection to this explanation was even 
stronger : A colleague of mine, disposed to 
hay-fever, who had helped me for many 
years, allowed himself to be injected with 
a solution of pollen albumin. One half- 
hour after the injection marked symptoms 
appeared in the eyes, nose, and mouth. 
The patient experienced pains in the chest, 
expectorated a tenacious, mucoid sputum, 
and perspired freely. The respiration be- 
came rapid and difficult, the pulse-rate was 
accelerated, and the voice grew weak. 
After fifty minutes there was a flat, urti- 
carial eruption over the whole body. After 
twenty-four hours all the results of the 
injection had not yet disappeared. At the 
site of the injection there was a marked 
swelling, which persisted for five days. 

"Injection of hay-fever toxin caused the 
same symptoms in me. A colleague who 

[ 223 ] 



HAY-FEVER 

did not suffer with hay-fever reacted to 
the same dose with a small, almost im- 
perceptible swelling at the site of the in- 
jection. Pollen albumin was, in other 
words, not toxic for him when introduced 
under the skin. Hundreds of experiments 
have proved to us that pollen albumin is 
not a poison in the ordinary sense of the 
word, and that even when introduced into 
the circulation it is inactive. Not only is 
the skin of hay-fever patients permeable, 
for the hay-fever poison in varying de- 
grees, but it also reacts to the toxin in dif- 
ferent ways in different patients. In some 
cases when a solution of pollen albumin is 
placed on the skin, there occurs within a 
few minutes an erythema. If, on the other 
hand, a patient is very susceptible to hay- 
fever, the skin may show absolutely no re- 
action when brought in contact with the 
toxin. These results may be of value in 

[224] 



FORMS OF TREATMENT 

the study of individual predisposition, 
since they enable ns to throw some light 
upon the question as to whether or not 
hay-fever is to be looked upon t*s a result 
of a hypersensitiveness. 

"In the first place, statistics have 
definitely proved that hay-fever has no 
relation to any constitutional disease, — for 
instance, gout; that, indeed, only a very 
small percentage of hay-fever patients are 
gouty. It is very commonly believed that 
hay-fever is due to some anomaly or stop- 
ping up of the upper air-passages. A local 
disease of the trigeminus is assumed by 
some, with a resulting sensitiveness on the 
part of certain mucous membranes. The 
falsity of these conceptions is clear from 
the experiments cited above. Not only 
does the whole skin-surface of many pa- 
tients react to the poison, but subcutane- 
ous infection is followed by characteristic 
[ 225 ] 



HAY-FEVER 

effects. By showing that the anal mucous 
membrane of hay-fever patients reacts to 
the pollen toxin, I believe that all those 
hypotheses, which assume only a local sen- 
sitiveness on the part of the cranial nerves, 
or the capital mucous membrane, is robbed 
of all support. Suggestion, as we have 
seen, plays a large part in the attempts to 
explain hay-fever predisposition. I can 
treat this question together with that of 
the role of specific odors of flowers, cats, 
dogs, etc. Two colorless, odorless solu- 
tions were prepared, and a drop from one 
of them was placed on the mucous mem- 
brane of the eye and nose of a large num- 
ber of hay-fever patients. Some reacted, 
others Hid not. None of them knew what 
sort of a solution was being used. The ap- 
plications were then made in a different 
way, each patient receiving a drop of the 
solution which had not been used in his 
[ 226 ] 



FORMS OF TREATMENT 

case before. Those who had reacted the 
first time did not do so the second. The 
one solution was physiologic salt, the other 
pollen albumin. None of the patients re- 
acted to the saline, all reacted to the other 
solution. In the course of many years I 
repeated these experiments with many 
variations. In the place of the salt solu- 
tion I used solution of albumin from in- 
active pollen. The results were always 
the same. In the face of such results, he 
who would explain hay-fever on the 
ground of suggestion, simply ignores all 
the facts to the contrary, and his opinion 
does not deserve serious consideration. 

"Hay-fever is looked upon as a result 
of an advanced culture and civilization. It 
happens that there are very few hay- fever 
patients in the laboring class, and that the 
Anglo-Saxon races, especially the Ger- 
mans, English, and Americans, furnish the 

[227] 



HAY-FEVER 

largest number of such patients. That 
hay-fever does at times occur among the 
Romans and other nations, I am able to 
gather from correspondence that I have 
had with inhabitants of such countries. In 
St. Louis I met an elevator boy who had 
hay-fever. Among the Anglo-Saxons the 
disease is found most often among pro- 
fessional men. Men appear to be twice as 
susceptible as women. It is often claimed 
that hay-fever follows a period of strenu- 
ous mental work, or of excitement, as, for 
instance, after examination, or in officers 
after maneuvers. Hay-fever has often 
been shown to be hereditary. Most fre- 
quently, however, a severe attack of in- 
fluenza has left hay-fever in its wake. 
Other causes, as, for instance, a difficult 
labor, are asserted by patients to have 
been the exciting cause of their hay-fever 

attacks. May we conclude from all these 
[228 ] 



FORMS OF TREATMENT 

facts that hay-fever is the result of a dis- 
turbance of the central nervous system? 

"It was formerly believed that all hay- 
fever patients were very nervous and ex- 
citable. This is certainly not universally 
true. If we are indeed dealing with a 
severe abnormality of the central nervous 
system this, in most instances, makes itself 
felt only in a hay-fever predisposition. 
Hundreds of hay-fever patients have writ- 
ten me that except during the season they 
are altogether well, and I have found 
among hay-fever patients many with 
phlegmatic dispositions. Those idiosyn- 
crasies which resemble hay-fever in a way, 
as, for instance, susceptibility to straw- 
berries, crawfish, iodin, antipyrin, bro- 
mids and the salts of quinin, are to-day 
explained on the ground of anaphylaxis. 

"Th. Albrecht declares that ten years 
ago every physician had his own theory 

[229] 



HAY-FEVER 

concerning the treatment of hay-fever. 
And I may add from my own experience 
that every patient also had his own method 
of treatment, which was, as a rule, very 
complicated. From my records it is very 
evident that many patients had ten or more 
hay-fever remedies, which they used either 
separately or together. A hay-fever pa- 
tient takes up at once every new remedy 
that appears and enthusiastically recom- 
mends it to others. As a rule, he learns 
of the new remedy near the end of the hay- 
fever season, and while he is using it his 
troubles disappear and he attributes his 
relief to the remedy he has been using. In 
the following spring he is undeceived. In 
this way one hay-fever remedy after an- 
other is consigned to oblivion only to re- 
appear later under a different name. The 
only remedies that have survived for any 
length of time are those with narcotic 

[ 230 ] 



FORMS OF TREATMENT 

effects, as cocain, adrenalin, anesthesin, 
morphin, etc. Concerning the danger con- 
nected with the use of these narcotics, it 
is surely not necessary to say a word. In 
addition, adrenalin and anesthesin and the 
remedies prepared from them cause in 
many cases a sensation that is much more 
annoying and unpleasant than hay-fever 
itself. I, myself, have tested all the hay- 
fever remedies on which I could lay my 
hands within the last ten years. With no 
one of them did I accomplish a beneficial 
result. There was indeed no reason to 
suppose that the remedy could accomplish 
the things that were claimed for it. It is 
easy to gather the same opinion if one 
reads the thousands or more hay-fever 
histories that I have in my possession. I 
have called attention above to the fact that 
on purely theoretical grounds nothing was 
to be expected from these preparations, 

[231] 



HAY-FEVER 

and that chance had not put into our hands 
a chemical preparation that was effective. 
Every physician must warn his patients 
against the use of narcotics. I shall, there- 
fore, not consider those remedies and 
methods of treatment that belong to this 
category. 

"In the thousands or more histories 
which I have been able to read, cauteriza- 
tion, burning, chiseling, and sawing in the 
nose play a large part. 

"It has been shown that the active al- 
bumin pollen is a substance of such 
marked specificity that the albumin which 
causes hay-fever symptoms in one patient 
(pollen of the grasses in Europeans) is 
entirely inactive in other patients (those 
with autumnal catarrh). On the other 
hand, the toxin of the ragweed has abso- 
lutely no effect on the European patients. 
By means of the complement deviation 

[ 232 ] 



FORMS OF TREATMENT 

method I could prove that this specificity 
could be shown in the hemolytic properties 
of the different albumins, the albumin of 
the grass pollen reacting altogether dif- 
ferently from that of goldenrod and rag- 
weed. In view of this state of affairs, it 
is not to be hoped that chance would fur- 
nish us a chemical substance that would 
either neutralize or render inactive the 
pollen albumin, or overcome the indi- 
vidual predisposition, which, as we have 
seen, is also strictly specific. I have come 
to the conclusion that we can accomplish 
our end in three ways only. 

" First, by finding localities where the 
specific cause does not occur; second, by 
protecting the eyes, nose and mouth of the 
patient from the pollen; third, by active 
immunization against the toxin, or the use 
of a specific antitoxin. 

"The first method is yearly employed by 
[ 233 ] 



HAY-FEVER 

many patients with success. The second 
method is also successful. Hay-fever pa- 
tients are free from symptoms in regions 
in which a specific pollen does not occur. 
This was to be expected from what we have 
learned about the cause of the disease. 
Thus many patients find relief on the sea- 
shore, in islands, and in barren mountain- 
ous districts. In Germany they go to Heli- 
goland. In the United States they retire to 
Fire Island, Long Beach, the White Moun- 
tains, Green Mountains, or Adirondack 
Mountains during the hay-fever season. 

"All my attempts of many years to get 
rid of the irritating contents of the horse 
serum have been in vain. As early as 1905, 
I realized that this would be so, for I 
proved then that the irritating substance 
(as I then called the anaphylactic agent) 
was bound to the euglobulin of the horse 
serum as was also the antitoxin itself. If 

[234] 



FORMS OF TREATMENT 

the cuglobulin is destroyed the antitoxin is 
at the same time rendered useless. I have 
been able to help patients who have become 
anaphylactic in two ways: First, by the 
use of pollantin R., and the suggestion 
to use this diluted serum only before the 
occurrence of the hay-fever attack, in the 
very smallest doses, and if possible only 
once daily. Patients who follow these di- 
rections have informed me that pollantin 
R. did not irritate them at first, altho it 
did so later. The irritation was, however, 
not severe and disappeared within ten to 
thirty minutes. After this the patient was 
free from hay-fever attacks for one or 
more days. Secondly, I have taken ad- 
vantage of the fact that horse serum ana- 
phylaxis is in most cases specific, but does 
not appear to me to be always so. I have 
seen instances in which during the develop- 
ment of a hypersensitiveness to one animal 

[235] 



HAY-FEVER 

serum, patients were rendered anaphylac- 
tic to the sera of other animals also. This 
does not, however, happen often. I have, 
therefore, administered to patients who 
could no longer stand pollantin R. a very 
active rabbit serum with good results. It 
was not only possible to ward off attacks 
with this serum, but also to protect pa- 
tients from further attacks during the hay- 
fever season. These results appear to me 
to support the opinion, which I exprest 
years ago, viz., that the reaction to the 
antitoxin, and with it the tendency toward 
definite immunization, is directly propor- 
tional to the degree to which anaphylaxis 
toward animal serum develops. Patients 
who have become anaphylactic get along 
with much smaller doses of antitoxin than 
other patients, and have, I believe, a better 
chance to effectually overcome their hay- 
fever predisposition. 

[ 236 ] 



FORMS OF TREATMENT 

4 1 This is the goal toward which we must 
strive, I know of many hay-fever patients, 
some of whom had attacks of the worst 
kind, who were entirely free after the use 
of pollantin for a very short time. I con- 
sider these people permanently cured, and 
so exprest myself in an article last year. 
A rhinologist interested in hay-fever wrote 
to me that he could not understand these 
successes, and that he and his colleague 
had never been able to obtain such results. 
He wrote further that my successful ex- 
periences were in marked contrast to the 
experienced German Hay-Fever Associa- 
tion. In answer to such communications 
I have placed my material in the hands of 
the secretary of this Association, Dr. Th. 
Albrecht. I was very much pleased to 
learn as a result that Dr. Albrecht had 
been able to cure and successfully immu- 
nize patients by means of pollantin. In a 

[ 237 ] 



HAY-FEVER 

recent publication, Dr. Albrecht reported 
twelve cases in which, after the use of pol- 
lantin for a short time, there resulted 
either a complete cure or at least a marked 
improvement. These observations are, of 
course, of intense interest to me. I would 
ask all colleagues who have made similar 
observations to be kind enough to com- 
municate them to me. I have only been 
strengthened in my former opinion that 
by means of a mixed passive and active 
immunization a permanent cure of hay- 
fever can be accomplished. 

6. Experiments with Autoserum. 

By Harold Hays, M.D. 1 

Within the past year a new advance has 
apparently been made in the treatment of 
various persistent and chronic dermatoses 
by the use of autoserum. Among those 

* Annals of Otology, Rhinology and Laryngology, 
June, 1915. 

[238 ] 



FORMS OF TREATMENT 

who have been doing a large amount of 
work in this direction are Dr. Wm. S. Got- 
theil and his associates. Gottheil in April 
of this year published his first report, 
which was followed later by a more 
lengthy survey of the subject. 

In this report the writer speaks enthu- 
siastically about the beneficial changes 
that take place, particularly in the cases of 
psoriasis. All of the cases treated were of 
long standing, with extensive lesions, in 
which the usual treatments were of no 
avail. Gottheil summarizes his experience 
with autoserum by stating "that it has a 
peculiar influence for good which enables 
us to clear off the skin in one-tenth the 
usual time, with very weak and innocuous 
local medication, and without any internal 
treatment at all." His results have been 
corroborated by Dr. John A. Fordyce and 
Dr. Howard Fox. 

[ 239 ] 



HAY-FEVER 

As a result of the encouraging reports 
in the treatment of the dermatoses by 
auto serum, it occurred to the writer that 
it would be worth while trying this same 
form of treatment in cases of hay-fever. 
He arrived at this conclusion after noting 
the similarity of hay-fever to various skin 
conditions. His premises may be sum- 
marized as follows : 

1. Hay-fever is a local manifestation 
of some internal derangement of the 
system. 

2. Hay-fever has associated with it 
a nervous element which results in a 
local paresis of the blood-vessels of the 
nose. 

3. Hay-fever occurs at well-regulated 
intervals, and mainly affects definite parts, 
namely, the mucous membrane of the nose, 
eyes, throat, and lungs. 

a. Psoriasis (with some other of the 

[240] 



FORMS OF TREATMENT 

dermatoses) is a local manifestation of an 
internal derangement of the system. 

b. Psoriasis has associated with it a 
certain nervous element. 

c. Psoriasis occurs in definite localities 
of the skin (mainly extensor surfaces). 

This line of reasoning was further sub- 
stantiated by reasoning along biologic 
grounds, for (1) there are certain anaphy- 
lactic reactions present in psoriasis and 
other dermatoses which are at the same 
time present in hay-fever and asthma. (2) 
A marked eosinophilia is present in the 
dermatoses and is also present in hay- 
fever and asthma. 

It was not, therefore, inconsistent or un- 
reasonable to suppose that if a definite 
improvement or even cure could be ob- 
tained from the use of autoserum in the 
dermatoses, it could be obtained in hay- 
fever and asthma. 

[241] 



HAY-FEVER 

The writer, therefore, began a series of 
experiments in August of this year, wait- 
ing until the patient was in the prime of 
his hay-fever attack before beginning the 
injections. 

Autoserum, as the name indicates, is a 
serum obtained from the patient into 
whom afterward it is to be injected. The 
method of obtaining this serum is very 
simple, and is as follows : A constricting 
bandage, preferably of rubber, is wound 
around the patient's arm above the elbow 
until it is tight enough to almost obliter- 
ate the pulse. In a few moments the arm 
becomes a dull purple from the venous en- 
gorgement, and a vein from which to draw 
the blood is readily selected. Very often 
the very superficial veins are too small, 
and a deeper one must be palpated for. The 
desired amount of blood may be withdrawn 
in a number of ways. At first the writer 

[242] 



FORMS OF TREATMENT 

used the MacRae needles, as suggested by 
Dr. Howard Fox. These needles are very 
small and are fitted into a rubber cork 
which can readily be inserted into a fifty 
cubic centimeter bottle. On one side is a 
thin narrow cannula, to which a piece of 
rubber tubing may be attached for suction. 
It is claimed that after the blood once 
starts to flow, a continuous stream may be 
kept up by proper suction through the 
rubber tube ; but it was the writer's experi- 
ence that on account of the small caliber 
of the needle it became clogged with co- 
agulated blood very readily, so that it was 
difficult to withdraw all the blood that one 
desired. He therefore had recourse to the 
simpler (and what seemed to the patient 
more barbarous) procedure of using a 
twenty-five cubic centimeter all-glass syr- 
inge to which could be attached needles 
of suitable length and caliber. He was 

[243] 



HAY-FEVER 

able in this latter way to withdraw as much 
as twenty-five to thirty cubic centimeters 
of blood. 

The blood was immediately projected 
into a sterilized fifty cubic centimeter 
bottle, made of suitable size so that it could 
be used in an electric centrifuge. 

This blood was then centrifuged at great 
speed for from twenty to twenty-five 
minutes, at the end of which time it was 
seen that the serum had been nicely separ- 
ated from the red blood cells. It should 
be straw-colored in appearance, but very 
often a small amount of the coloring mat- 
ter of the blood tinges it, which apparently 
does no harm. 

This serum was then drawn up into a 
sterilized all-glass syringe and reinjected 
into the patient, either subcutaneously or 
intravenously. The writer found the 
former method satisfactory, and in no in- 

[ 244 ] 



FORMS OF TREATMENT 

stance was there any untoward results. 
A large swelling often appeared at the 
time of the injection, but this disappeared 
within a few honrs. 

Tn a few instances when the centrifuge 
was out of order. It was necessary to al- 
low the blood to stand overnight in the ice- 
box. The separation under these circum- 
stances was just as good, but whether any 
chemical change took place, it is impossible 
to say. 

In this series of experiments twelve 
cases were treated. The treatments were 
given in the writer's office, under the best 
conditions possible. Each patient was in- 
telligent enough to let him know in a sat- 
isfactory way just what results there were 
from the injections. At first there seemed 
to be a period of vast improvement, and he 
was in hopes that we were at last on the 
road to a discovery of some specific cure. 

[245] 



HAY-FEVER 

However, the improvement lasted but a 
very short time, and then the patients were 
just as bad as ever. It is, therefore, 
necessary to report these experiments 
from a negative point of view, in the hope 
that it will lead others to do further re- 
search work along the lines of experi- 
mental biology. 

It will be noticed in the cases which are 
reviewed that the amount of serum injected 
was very much smaller than that used by 
skin specialists. Grottheil in his later 
paper speaks of one case where he with- 
drew as much as one hundred and fifty 
cubic centimeters of blood, from which 
he obtained seventy cubic centimeters of 
serum. In these cases the largest amount 
of serum injected was fifteen cubic centi- 
meters, but it seems that it should have 
been possible to obtain a reaction of some 
sort from this small amount, if the treat- 

[246] 



FORMS OF TREATMENT 

ment was going to do any good at all. 
Again, it is possible that in the treatment 
of the dermatoses the injection of such 
large amounts of serum was not necessary. 
As the susceptible hay-fever patient is 
very sensitive to an infinite stimal amount 
of pollen, it is not unreasonable to suppose 
that moderate amounts of serum ought to 
show some reaction, if the treatment were 
to be worth anything at all. 

It is worthy of note in the series of cases 
under observation that most of the pa- 
tients had tried many of the newer treat- 
ments for hay-fever, and in no instance 
was even a semblance of a cure effected. 
A few of the cases are detailed below : 
Case 1. — Mrs. K. First attack of hay- 
fever nine years ago, returning each year 
and lasting from about the 15th of August 
to the end of September. She tried no 
cures except "cold" remedies until this 

[247] 



HAY-FEVER 

year, when she was given hypodermic 
injections of some serum two or three 
times a week during the hay-fever period, 
but with no benefit. After the season was 
over she was in a general run-down con- 
dition. 

On August 17th this patient had ten 
cubic centimeters of blood withdrawn; on 
August 19th, nineteen cubic centimeters; 
August 21st, twenty-five cubic centimeters ; 
and August 25th, thirty cubic centimeters. 
At the first sitting five cubic centimeters 
were injected subcutaneously in the arm; 
on the 19th, twelve cubic centimeters; on 
the 21st, ten cubic centimeters were in- 
jected into the buttocks, and on the 25th, 
eight cubic centimeters were again injected 
into the arm, the blood had stood in the 
ice-box for twenty-four hours. During the 
first week the patient seemed considerably 
improved, but after that time there was a 

[248] 



FORMS OF TREATMENT 

retrogression, and the patient was as badly 
off as ever. This patient has a general 
hypertrophy of all the mucous membrane 
of the nose. 

Case 2. — Major D., whose hay-fever 
dates from 1889. He found that when he 
was away from the United States he had 
no hay-fever, but if he returned to this 
country in the summer it would be just as 
bad as ever. He had been stationed in 
Washington, West Virginia, Portland, 
Oregon, and other places, and in every 
place had hay-fever. He had tried atropin, 
adrenalin chlorid and sprays of various 
kinds, with no relief. 

Twenty cubic centimeters of blood were 
withdrawn on August 17th, half the 
amount in serum being reinjected, and the 
procedure repeated on August 19th. The 
patient then left for Porto Rico. His 
statement of his symptoms was as follows : 

[249] 



HAY-FEVEB 

August 18th he was worse ; there was some 
discomfort most of the day. After the 
second treatment, until night he seemed 
considerably better, but he woke up with a 
sensation of swelling in the right nostril. 
On the 20th he had very little discomfort 
all day. On the 21st he had an attack last- 
ing for two hours. On the 22d he sailed 
for Porto Bico, arriving there on the 27th 
of August with apparently no symptoms. 

In the conclusion of the report the pa- 
tient says: "Comparing this attack with 
my best recollections of previous attacks, I 
should say that the attack I had on the 
night of August 19th was similar to a pre- 
vious one six years before. To the best 
of my judgment the attack this year pro- 
gressed at its usual rate, and was in no 
manner retarded by the two treatments 
administered. " 

Case 3. — Mrs. F. had her first attack of 

[ 250 ] 



FORMS OF TREATMENT 

hay-fever in 1908. Adrenalin was pre- 
scribed with no result. A new attack came 
on while the patient was in England the 
following year. "Walking in the open 
seemed to help. "This year I have worked 
in my garden and played tennis, always 
either to w^ard off an attack or more often 
to cnre one." 

The patient received two injections of 
ten cubic centimeters, from twenty-two 
cubic centimeters of blood withdrawn. 
The injections had apparently no benefi- 
cial effects. 

Besides these seven cases, five others 
were treated, the reports of which would 
be but a repetition of the above. Each was 
given two or more injections, ranging in 
amount from five cubic centimeters to fif- 
teen cubic centimeters of serum. In every 
instance the treatment was a failure. 

Moschowitz draws attention to the fact 

[251] 



HAY-FEVER 

that the various common diseases in which 
anaphylactic reactions are present are 
usually associated with an eosinophilia. 
"In asthma, hay-fever, and urticaria the 
blood contains an excess of eosinophiles ; 
the secretions of the bronchus and of the 
nose in asthma and hay- fever, respectively, 
are filled with eosinophile leucocytes. In 
urticaria, also eosinophilia, both local and 
general, are found in nearly all skin-lesions 
{e.g., eczema, prurigo, Diihring's disease, 
pemphigus, psoriasis, etc.) . . . In con- 
nection with the association of many of the 
manifestations of the exudative diathesis 
in ' neurotic' individuals, it is significant 
that Neusser and others have shown that 
eosinophilia is a common finding in such 
individuals/ ' 

The writer feels that he can best con- 
clude by repeating Koessler's last words: 

"I wish to express emphatically a word 

[ 252 ] 



FORMS OF TREATMENT 

of caution. It will not be long before the 
commercial manufacturers of vaccines see 
1 the great advantage and benefit' of this 
treatment. Hay-fever vaccines will be 
praised and advertised and put up so at- 
tractively that their rise will become uni- 
versal, and soon universally discredited. 
For the pollen extract is not stable, es- 
pecially not the higher dilutions. By pro- 
gressing proteolysis, after three to four 
weeks, it acquires marked toxic properties 
which lead to severe reactions. The solu- 
tions must, therefore, be freshly prepared 
every eight or ten days, if these reactions 
are to be avoided. Whatever the method 
of active immunization, whatever the dos- 
age and technic, the one sound basis that 
must underlie all these endeavors is that 
the material to be injected must be not only 
sterile, but constantly of uniform potency 
if used in the same dilution. No extract 

[ 253 ] 



HAY-FEVER 

of pollen can comply with this demand if 
it is older than three weeks." 

7. Dr. E. T. Manning's Views 1 

Dunbar elected to immunize passively, 
and his well-known pollantin is the out- 
come of his efforts. He injected horses 
with gradually increased doses of ragweed 
pollen, with the expectation that a specific 
antibody would eventually be formed in 
the serum in sufficient amount for prac- 
tical use. He hoped that by injecting this 
antiserum into a sensitized human being, 
he would be able to neutralize the effect of 
the protein poison. Thus he assumed that 
the pollen protein acted as a true toxin. He 
was rewarded with a moderate degree of 
success. 

Koessler, of Chicago, first began his 

1 Journal of the American Medical Association, Feb- 
ruary 20, 1915, p. 655. 

[254] 



FORMS OF TREATMENT 

work in active immunization in 1910. He 
used ragweed pollen and treated only 
cases of the autumnal catarrh variety. He 
was the first to report definite methods of 
preparing pollen solutions, and to him 
must be given the credit of placing this 
form of the treatment on a scientific basis^ 
He gave injections both in a prophylactic 
way, before the appearance of the hay- 
fever symptoms, and after the disease had 
been established. His results correspond 
closely with those of the English investi- 
gators. He reports ten per cent, absolute 
cures, seventy per cent, markedly im- 
proved subjectively and objectively, twelve 
per cent, subjectively improved, and eight 
per cent, not affected. 

I treated twenty-one cases; fourteen 
were objectively and subjectively relieved ; 
in the other seven the treatment was in- 
complete for one reason or another. Two 
[255 ] 



HAY-FEVER 

of these seven showed no reaction, either 
good or bad. Four more were certain that 
their attacks were lighter. One patient 
was undoubtedly made worse, a result 
which I think was due entirely to a mis- 
take of judgment on my part in giving her 
a large dose without gradually working up 
to it. Three of the cases had a bad asthma 
complicating. Two of these were com- 
pletely under control and the other was 
much relieved. 

It is difficult to determine exactly what 
should be designated as a cure. Many 
years ago a great medical philosopher, 
who was no pessimist in regard to treat- 
ment, gave as an aphorism, "Nothing ever 
gets completely well." It is true that 
there are few disease processes which do 
not leave their impress on the organism 
in some chemical, anatomic or functional 

alteration. Our desire to apply the word 
[256 ] 



FORMS OF TREATMENT 

"cure" to a treatment probably arises 
from the effort to keep pace with the medi- 
cal charlatans who are only too anxious to 
guarantee so-called cures. So in hay-fever 
— a disease which is extremely susceptible 
to all the changes in nervous control of the 
individual, with some symptoms exceed- 
ingly vague and influenced to a large ex- 
tent by the imagination — it is very difficult 
to determine just what part this or that 
remedy plays in modifying the disease 
process, and in thus assisting in a cure. 

Statistics concerning the effect of a 
therapeutic measure are decidedly unre- 
liable as a guide. But few persons, and 
these only in rare instances, act on statis- 
tics alone. They act rather on experience, 
either their own or of others. When they 
do this they are on surer ground than 
when they rely on bare figures alone. 

[257] 



HAY-FEVER 
8. The Use of Phylacogen 

By I. H. Alexander, M.D. 1 

The value of Phylacogen in the treat- 
ment of diseases seems to depend upon 
whether we are to take the reports of the 
experiences of many physicians scattered 
throughout the civilized world, who have 
intelligently used this form of treatment 
and have obtained results which they be- 
lieved are better than those obtained by 
other methods, or whether we are to de- 
pend upon the advice given by the many 
and voluminous articles appearing in the 
medical journals, principally in the Jour- 
nal of the American Medical Association, 
which condemns the use of Phylacogen 
from every point of view. There is no rea- 
son to believe that the articles appearing 
in the Journal of the American Medical 

1 Pittsburgh Medical Journal, July, 1914. 
[ 258 ] 



FORMS OF TREATMENT 

Association are not sincere and represent 
correctly the views of the writers of these 
articles, as well as those of the editor. 

It is not the intention of the writer to 
defend or recommend the use of Phylaco- 
gen in the treatment of hay-fever, asthma 
or any other infection, but as it was my 
privilege to Be the first physician, as far 
as I have been able to learn, to use this 
method of treatment for the relief and 
cure of these most annoying and painful 
conditions, I desire to report my results 
and give, as near as possible, my methods 
of administration. I do not wish to give 
the impression that the administration of 
the Mixed Infection Phylacogen consti- 
tutes the entire treatment of hay-fever 
and asthma, altho many cases will recover 
without additional treatment. I consider 
it only as a very great aid in the medica- 
tion and should be used in conjunction 

[ 259 ] 



HAY-FEVER 

with other remedies, given for the relief of 
symptoms, etc. Pottenger says of the use 
of Tuberculin in tuberculosis, there is 
more to the Tuberculin treatment than 
having a patient suffering from tubercu- 
losis and a syringe loaded with Tuberculin 
to inject into him. 

My experience with Mixed Infection 
Phylacogen in the treatment of bronchial 
asthma has been somewhat more extensive 
than my hay-fever experience. Thirty-six 
cases have been treated to date. Only one 
case insisted that he had not been bene- 
fited. This case had found relief from his 
suffering by the hypodermic use of Adren- 
alin, which he administered himself, often 
using as high as twenty injections a day. 
This case improved on Mixed Infection 
Phylacogen at first, and for two weeks was 
symptomatically well. Physical examina- 
tion of the chest at that time failed to de- 

[ 260] 



FORMS OP TREATMENT 

tect the physical signs of bronchial asth- 
ma, but within a week of the time of the 
last examination he was suffering just as 
severely as before, and was using his 
hypodermic syringe as frequently as ever. 
Physical examination did not present suf- 
ficient evidence to account for his apparent 
severe dyspnoea. This case, I believe, had 
formed the habit of using Adrenalin. Of 
the other thirty-five cases, thirty recov- 
ered and have remained well from one to 
three years. Two cases have recurred 
twice and were finally cured by administer- 
ing Salvarsan. 

9. The Calcium Salt Treatment 

By Harold Wilson,, M.D. 1 

The reports of Emmerich and Loew 2 on 
the very favorable results secured by them 

1 Gouty and rheumatic cases are undoubtedly much 
benefited by the use of calcium salts as Dr. Wilson 
points out in this article. 

3 Emmerich and Loew: Erfolgreiche Behandlung 

[261] 



HAY-FEVER 

from the prolonged administration of cal- 
cium chlorid in the treatment of hay-fever 
induced me to make some trial of this drug 
during the season of 1915. A brief report 
of the results will be given in this com- 
munication. 

Whether the ingestion of calcium salts 
has a direct inhibitory action on the pro- 
teolytic reactions which appear to be a 
necessary part of the hay- fever complex, 
or so modify this reaction as to render the 
split proteins less toxic, or whether they 
act by lessening the patient's nerve irri- 
tability, seems at this time to be quite un- 
determined. The employment of calcium 
salts in hay-fever would be on a much bet- 
ter basis if we were able to rationalize it. 
At present, it seems to me that this method 

des Heufiebers durch lange Zeit fortgesetzte Chlorkal- 
ziumzufiihr, Miinchen. med. Wchnschr., 1913, lx, 2676; 
Weitere Metteilungen iiber Erfolgreiche Behandlung 
des Heufiebers, ibid., 1914, lxii, 41. 

[262] 



FORMS OF TREATMENT 

of treatment can hardly claim to be more 
than "reasonable empiricism." In view 
of the fact, however, that much other use- 
ful therapy rests on a no more secure foun- 
dation than this, there is no reason why we 
should not make a sufficient trial of this 
method, which has, certainly, many prac- 
tical advantages. 

Twenty-six patients were treated by me 
during the past season. Of these, twenty- 
two were treated exclusively with calcium 
chlorid, and four patients, who had been 
under treatment by means of injections of 
pollen solution, were given the drug when 
their hay-fever symptoms began to de- 
velop more or less severely. 

One patient had hay-fever of the vernal 
type only; three patients had both vernal 
and autumnal attacks, and twenty-two pa- 
tients had only autumnal attacks. Twenty- 
two patients gave a positive ophthalmic 
[263 ] 



HAY-FEVER 

or cutaneous reaction to ragweed pollen; 
four gave a negative reaction to ragweed. 
Many cutaneous tests were made with sub- 
stances other than pollens, the result of 
which will be made the subject of another 
report. 

Treatment was begun in June, with 
seven patients ; in July with four ; in Au- 
gust with fifteen, and in September with 
two. In no case did any patient take the 
drug for more than eight or ten weeks be- 
fore the time of the expected attack, and 
in most cases the period was much more 
brief. Emmerich and Loew advise the use 
of the drug over a very long period, as 
much as a year, if possible. Altho it has 
been shown that the maximum calcium 
retention in the system occurs only after 
its prolonged ingestion, it remains to be 
proved that its optimum therapeutic effect 
in hay-fever requires its daily use for a 
year before the expected attack. In some 

[264] 



FORMS OF TREATMENT 

of the most favorable cases here reported, 
the relief secured came almost at once, or 
after taking, at most, only a few doses. 

For most patients the calcium chlorid 
was prescribed thus: 

Calcium chlorid crystals 100 gm. 

Distilled water to make 500 c.c. 

M. Sig. — Take one teaspoonful in sufficient 
water during or after each meal. 

This gives the patient about 3 gm, of cal- 
cium chlorid daily. The crystalline salt is 
used in preference to the anhydrous, as 
making a cleaner and clearer solution. 
When the anhydrous salt is prescribed, al- 
lowance should be made for the water of 
crystallization, of which in the crystalline 
salt there are six molecules (CaCl 2 +6 
H 2 0) : 

Calcium chlorid, anhydrous 50 gm. 

Distilled water to make 500 c.c. 

M. Sig. — Take one teaspoonful in sufficient 
water with or after each meal. 
[ 265] 



HAY-FEVER 

There was no serious difficulty in taking 
the drug as thus prescribed. One patient 
experienced gastric distress until the dose 
was reduced ; another complained of weak- 
ness and loss of appetite, and had to use 
it intermittently in a lessened dose; an- 
other thought it caused a diminution in the 
urinary output, while another thought the 
flow of urine was increased. It has not 
been observed that the daily ingestion of 
3 gm. of calcium chlorid has been followed 
by any marked bodily disturbance. In 
fact, much larger doses than this can 
apparently be taken with entire safety. 
Cow's milk contains 0.198 per cent, cal- 
cium monoxid. A pint of milk contains 
about 0.71 gm. calcium. Three gm. of cal- 
cium chlorid crystals contain about 0.55 
gm. calcium, so that more lime is taken by 
the daily use of a pint of milk than in the 
dosage prescribed above. 

[ 266 ] 



FORMS OF TREATMENT 

The table on page 268 gives the results 
of the treatment with calcium chlorid in 
the twenty-six cases under observation. 

A few of the most favorable reports are 
given in greater detail: 

Case 23.— Miss M. T., aged 21, had had 
hay-fever since childhood, beginning in 
May and lasting until frost. She was sen- 
sitive to flowers of all kinds, to dust and to 
wind. She could not sweep floors without 
marked discomfort. She had no asthma. 
Eye and nasal symptoms were most 
marked. She had been using epinephrin 
solutions until they now aggravated the 
trouble. July 2d there were lacrimation, 
coryza and sneezing of moderate severity 
more or less continuously. Ophthalmic 
and cutaneous reactions to ragweed were 
negative. Calcium chlorid, 1 gm., three 
times a day, was prescribed. July 9th, 
eyes were "wonderfully better"; there 

[267] 



HAY-FEVER 



RESULTS OF TREATMENT WITH CALCIUM CHLORID IN 
TWENTY-SIX CASES.* 





Type 


Reac- 


Duration 






Case 
No. 


of 
Hay- 


tion 
to 


of 
Treat- 


Result 


Remarks 




fever 


Rag- 
weed 


ment 






12 


A 


+ 


2-3 weeka 


+ 


Under treatment with injections of 
pollen solutions for ten weeks 
previously. 

Previous treatment as in Case 12. 


13 


A 


+ 


2-3 weeka 


+ 


14 


A 


+ 


2-3 weeka 


+ • 


Previous treatment as in Case 12. 


19 


A 


+ 


2-3 weeka 


+ 


Previous treatment with injections 
of pollen solutions seven weeks. 


22 


A 


+ 


10 weeka 







23 


A-V 




13 weeka 


+ + + 


Immediate improvement and abso- 
lute freedom from all symptoms 
after July 28. 

Multiple sensitization. 


24 


A 


+ 


11 week8 


+ + + 


25 


A 


+ 


13 weeks 


+ 


No symptoms until September 1. 


26 


A 


+ 


16 weeks 


+ + + 


No symptoms until September 25. 
Then only trifling itching in throat 
and slight sneezing. No other 
symptoms. 


27 


A 


+ 


12 weeks 


— 


September 25, patient writes, "I 
was worse than usual." 


29 


A 


+ 


8 weeka 


+ + + 


Only slight symptoms. 


30 


A 


+ 


3 weeka 


+ 




31 


A 


+ 


9 weeks 


+ 


Multiple sensitization (faint). 


32 


A 


+ 


4 weeks 


+ 


Multiple sensitization. 


83 


V 




9 weeks 


+ + 


Immediate relief and practical free- 
dom from all symptoms about 
half the time. 


34 


A-V 


+ 


5 weeks 


+ 


Reports moderate relief from symp- 
toms during season. 


35 


A 


+ 


4 weeks 


+ 


Multiple sensitization. 


36 


A 


+ 






No report. 


37 


A 


+ 


5 weeks 


+ + 


Very little hay-fever, even in 
country. 
Multiple sensitization. 


38 


A 


+ 


4 weeks 


+ 


39 


A 


f 


4 weeks 


+ 




40 


A 


+ 


4 weeks 


+ + 


Multiple sensitization. 


41 


A 


1 + 


4 weeka 


+ + 


Did not take drug regularly. 


42 


A 




5 weeks 


+ + + 


Peach reaction positive; stopped 
eating peaches. 


43 


A 


+ 


2 weeks 


+ 


Left city early in September. 


44 


A-V 




13 weeks 


+ + + 


Relief immediate and complete; 
slight recurrences; took drug very 
irregularly. 



♦Explanation of signs: A indicates autumnal; V, vernal; — , symptoms 
worse than usual; 0, symptoms about the same as usual; +, symptoms less 
marked than usual; -h-f» symptoms much leas marked than usual; very 
definite improvement; 4--I--K absolute freedom from symptoms, or only 
trifling and insignificant ones during season. 

[ 268] 



FORMS OF TREATMENT 

were somewhat less sneezing and coryza; 
the patient was less sensitive to dust 
and wind. July 20th, she was much 
less uncomfortable than usual. On the 
whole, there was a marked amelioration 
of symptoms. July 28th, there was very 
great relief. The patient was practically 
free from all symptoms. "I never was 
so helped by anything before." August 
13th, the patient reported that she had 
had no hay-fever symptoms whatever since 
last visit. Relief was absolute. Septem- 
ber 6th, absolute freedom from symptoms 
continued. This relief continued through- 
out the season. 

Case 26. — Miss M. R., aged 25, had had 
autumnal hay-fever seven or eight years; 
no asthma. Maternal aunt had had hay- 
fever since childhood. Ophthalmic and 
cutaneous reactions to ragweed were posi- 
tive. June 11th, calcium chlorid was pre- 

[269] 



HAY-FEVEK 

scribed, 1 gm. three times a day, but owing 
to some gastric distress which it seemed to 
cause, the dose was much reduced for sev- 
eral weeks. The full dose, however, was 
taken later and continued. No hay-fever 
symptoms were experienced until Septem- 
ber 5th, when there was slight sneezing, 
and itching in the throat. During the rest 
of the season symptoms were practically 
absent. 

Case 29.— Dr. W. A. K., aged 40, had 
had autumnal hay-fever for fifteen years, 
and slight asthma recently. July 7th, cal- 
cium chlorid was prescribed, 1 gm. three 
times a day. Patient reported in October 
that he had experienced only trifling symp- 
toms at any time during the season. 

Case 33.— Miss F. P., aged 43, had had 
vernal hay-fever, usually beginning about 
June 1st and lasting until the end of July. 
June 12th, she was having about the usual 

[270] 



FORMS OF TREATMENT 

amount of trouble. The ophthalmic reac- 
tion to ragweed was negative. Calcium 
chlorid, 1 gm. three times a day, was pre- 
scribed, with much relief, almost at once. 
She reported, August 25th: "I have been 
practically free from symptoms about half 
the time. The rest of the time partly free 
and partly in trouble. About July 28th 
took a long railway journey, weather dry 
and dusty, with no hay-fever symptoms at 
all." 

Case 42.— F. W., aged 28, had had hay- 
fever, beginning in August, for several 
years. Father had hay-fever ; no asthma. 
Ophthalmic and cutaneous reactions to 
ragweed were negative. Cutaneous and 
nasal reaction to peaches was positive. 
Calcium chlorid, 2 gm. three times a day, 
was prescribed. August 25th, the patient 
was very comfortable, with scarcely any 
symptoms. Cutaneous reaction to peaches 

[271] 



HAY-FEVER 

was negative. The patient had stopped 
eating peaches. During the rest of the 
season there were very few hay-fever 
symptoms. 

Case 44. — Miss C. S., aged 25, had had 
hay-fever for nine years, beginning in 
early spring and lasting until the second 
week in October. She had asthma. Symp- 
toms were marked. June 30th, the hay- 
fever symptoms were distressing. Oph- 
thalmic and cutaneous reaction to ragweed 
was negative. Calcium chlorid, 1 gm. three 
times a day, was prescribed. Patient re- 
ported September 25th. The hay-fever 
symptoms, which were severe, disap- 
peared after the second dose of the 
medicine, whereupon she promptly stopt 
taking it regularly. Afterward she took 
a long auto journey without symptoms. 
During the summer she had occasional 
slight symptoms, which disappeared im- 

[272] 



FORMS OF TREATMENT 

mediately when she took the medicine. She 
had been practically free from all hay- 
fever symptoms ever since beginning to 
take the drug. She thinks the results are 
" wonder ful." She would probably have 
taken the drug more regularly if it had not 
seemed to increase the secretion of urine. 

1. Some hay-fever patients taking not 
less than 3 gm. of calcium chlorid daily, 
even for a short time, are practically re- 
lieved from all hay-fever symptoms. 

2. Calcium chlorid may be taken in 
doses of 3 gm. daily for an indefinite time 
without any apparent injury. 

3-. It is not indispensable in all cases for 
a hay-fever patient to take calcium chlorid 
over a long period of time in order to se- 
cure relief. 

4. Calcium salts may be given, even 
when the nature of the patient's sensitiza- 
tion is not known. 

[273 ] 



HAY-FEVER 

5. The clinical results from the admin- 
istration of calcium chlorid in cases of 
hay-fever are such as to warrant its 
further trial. 

10. The Pollen Therapy Treatment 

By J. L. Goodale. 1 

The object of the following paper is to 
report the results of observations based 
upon one hundred and twenty-two cases of 
hay-fever examined during the past twelve 
months, with reference to determining, if 
possible, the value of pollen therapy treat- 
ment, and also to ascertain what biologic 
relations, if any, exist between the pollen 
of different plants. 

In the first place, a word should be said 
in regard to the method of obtaining and 
preserving the pollen extracts. For many 
plants, which furnish an abundance of 

1 Annals of Otology, Rhinology and Laryngology, 
June, 1915. 

[274] 



FORMS OF TREATMENT 

easily detached pollen, it is sufficient to 
gather the partially opened flowers, bring 
them into a room without currents of air, 
and in the course of a few days the pollen 
may be shaken upon smooth paper. This 
applies particularly to those plants the 
cross fertilization of which is effected 
through the agency of air currents, such as 
many forest trees and grasses, and certain 
Composite, particularly ragweed. In the 
entomophylous plants, where the cross fer- 
tilization is largely effected by the agency 
of insects, the freshly opened anthers may 
be dipt and gathered. The pollen is 
then either placed in the solution for ex- 
traction, or it may be preserved dry for 
an indefinite period. I have taken the 
pollen from specimens in my herbarium, 
gathered twenty-five to thirty years ago, 
of grasses and of ragweed, which on the 
addition of water excites as marked a skin 

[275] 



HAY-FEVER 

reaction as would be the case with, freshly 
prepared extract. 

The extract is obtained from the pollen 
by soaking in water for a few hours. I 
have not found it necessary to subject the 
material to trituration, as advised by some 
writers; and this is also theoretically 
unnecessary, since the pollen grains in 
water promptly undergo a swelling, with 
solution of their albuminous contents. 
Several observers have complained of the 
difficulty of preserving the extract, and 
say that it is liable to deterioration on 
standing. After a number of tests, an 
alcohol dilution of thirteen to fifteen per 
cent, seems to meet the requirements; 
and material prepared in this way a 
year ago has apparently lost but little of 
its efficiency. It is interesting to observe, 
in this connection, that we have an ex- 
ample of natural plant juice, namely, 

[ 276 ] 



FORMS OF TREATMENT 

wine, in which preservation of its qual- 
ities is thus secured. The heavier nat- 
ural wines contain a considerable amount 
of albuminous matter, together with ap- 
proximately fourteen per cent, alcohol. 
More than this percentage checks the fur- 
ther development of the yeast plant, and 
this amount, while preventing decompo- 
sition, does not seem sufficient to cause a 
precipitation of the proteids of the wine. 
It is desirable to keep the solution in am- 
ber bottles. 

A word of caution should be said in re- 
gard to the gathering of flower heads for 
the preparation of pollen extract in the 
case of those plants which may contain 
a poisonous substance, as occurs in cer- 
tain Composite, especially the wormwood 
group. I have observed a few cases 
where disturbing symptoms of nausea and 
malaise followed the injection of such 

[ 277 ] 



HAY-FEVEK 

materials to a greater extent than would 
be accounted for by the actual amount of 
pollen present. In the case, however, of 
such plants as the Bosaceae and grasses, 
these precautions are unnecessary, and we 
may, in the case of the latter, find it more 
convenient to strip off the flower heads or 
anthers by hand. 

When the pollen has been gathered and 
a suitable extract prepared, the latter con- 
stitutes then the stock solution from which 
varying dilutions are prepared. It is theo- 
retically desirable to prepare a stock solu- 
tion with a definite percentage of pollen 
extract; but practically this is unneces- 
sary, since individuals differ very widely 
in their degrees of sensitization, and each 
case must be examined by different dilu- 
tions to determine the correct strength 
which it is safe to use for him. 

The intensity of the skin reaction does 
[278 ] 



FORMS OF TREATMENT 

not always seem to be proportionate to the 
clinical symptoms of hay-fever. I have 
seen numerous severe cases where the 
skin reaction was much less than in other 
individuals, who apparently suffered from 
a milder form of the disease. In the case 
of children, the skin disturbances are rela- 
tively less pronounced than in the case of 
adults, and I have observed several under 
ten years of age, with apparently well de- 
fined hay- fever, who showed no reaction to 
the prevailing pollens borne in the air at 
the special season. 

In describing the results which have fol- 
lowed the injection of pollen extracts, it 
has seemed to me desirable to separate 
those cases which have received treatment 
during the hay-fever season from those 
which have been treated during the winter 
or out of season. I have done this for the 
reason that it is difficult to draw accurate 

[279 ] 



HAY-FEVER 

deductions from the statements of the pa- 
tients themselves. We have, in the first 
place, to remember that seasons vary in 
the severity of hay-fever symptoms, de- 
pendent upon the amount of rain, heat and 
cold. Furthermore, the individual's pre- 
disposition seems to vary, perhaps as the 
result of his physical state and habits at 
the season. Finally, the element of sug- 
gestion may conceivably play a part. 
While I shall, therefore, report the sum- 
mer cases with reference to the degree of 
relief obtained, I do not regard these fig- 
ures as at all conclusive. On the other 
hand, observations carried out during the 
winter with reference to changes in the 
intensity of the skin reaction, may be 
considered a fairly reliable guide, if it be 
admitted that the strength of the solutions 
themselves has not undergone deteriora- 
tion. This latter point is difficult to deter- 

[280] 



FORMS OF TREATMENT 

mine with absolute certainty. Neverthe- 
less, my alcoholic solutions seem now, 
after the lapse of months, to effect in new 
cases nearly, if not quite, the same degree 
of skin reaction which they occasioned 
when in a fresh state. 

At the date of writing, one hundred and 
twenty-two cases have been observed, of 
which seventy-four have had more or less 
treatment, and forty-eight have been seen 
but once, or are now beginning treatment. 
Of the cases which may have been consid- 
ered to have had a sufficient amount of 
treatment to enable us to draw more or 
less definite conclusions, thirty-two were 
treated after the onset of the hay-fever 
symptoms, and forty-seven were treated 
during the winter or early spring. Of 
these cases which were treated at the 
beginning or immediately before the hay- 
fever season, twenty-six exprest them- 

[281] 



HAY-FEVER 

selves as having been more or less re- 
lieved, eight could not see material im- 
provement. In estimating the results 
actually achieved by treatment during the 
season, I believe that an accurate judg- 
ment would place the extent of the relief 
in a number of instances distinctly below 
that which the patients exprest. In other 
words, I believe the element of sug- 
gestion plays here a considerable part. 
Furthermore, a certain number of these 
who believed themselves improved showed 
but slight diminution in the extent of the 
skin reaction. It has seemed to me that 
such cases probably represent too high a 
degree of sensitization to obtain material 
relief during the hay-fever season, and 
that a longer period of treatment is re- 
quired. On the other hand, several of 
these individuals who reported some 
months later showed a marked diminution 

[ 282 ] 



FORMS OF TREATMENT 

of tlieir skin reaction, and it was possible 
then to undertake their treatment with the 
result of bringing about still further a 
diminution in the intensity of the skin dis- 
turbances. About one-fourth, however, of 
those treated during the season expe- 
rienced after a certain number of injec- 
tions, ranging from four to twelve in 
number, such striking diminution in their 
subjective sensations and in the skin reac- 
tions, that it seemed difficult to ascribe the 
gain to anything else than the treatment, 
the improvement noted having occurred 
from one to three weeks before the disap- 
pearance of their type of hay-fever in this 
vicinity. 

Serobiologic methods have shown the 
phylogenetic relationship of the different 
plant orders and families. The applica- 
tion of these discoveries to the treatment 
of hay-fever by injection of plant proteids 

[ 283] 



HAY-FEVER 

promises to assist in the selection of the 
specific material required for a given case. 
Definite reactions are elicited in hay- 
fever by the pollen of the exciting plants 
when brought into contact with an abra- 
sion of the skin. The intensity of these 
skin manifestations may be sensibly di- 
minished by the repeated parenteral ad- 
ministration of the proteids in question. 
Coincident with the diminution of the skin 
reactions there seems to occur an in- 
creased tolerance of the exposed mucous 
membranes to the pollens of the plants em- 
ployed. Pollen therapy in hay-fever may 
be regarded at the present time as a prom- 
ising method of treatment, but its value 
and the permanence of its results remain 
still to be definitely established. 



[2S4] 



FORMS OF TREATMENT 

11. Surgical Treatment 

Surgical treatment of hay-fever is fre- 
quently necessary when the patient comes 
to the physician in the midst of the dis- 
ease and palliative measures are not pos- 
sible. In this case I cauterize the small 
sensitive areas with a flat electrode at a 
white heat, and without the use of cocain, 
as the use of a local anesthetic would make 
it impossible to find the sensitive spot. It 
is well to find the sensitive areas with the 
cold electrode, then turn on the current 
and bring to a white heat. In this way you 
can cauterize four or five sensitive areas 
at one time. Cauterization should not be 
repeated more frequently than every six 
or seven days. 

Nasal catarrh, nasal polypi, deviation of 
the septum, as well as sinusitis, should be 
treated long before the paroxysms. Many 

[ 285 ] 



HAY-FEVER 

authorities, including Ballinger, believe 
sinusitis is hay-fever, and, if this is true, 
selected cases respond to autogenous vac- 
cine. Ballinger quotes Dr. P. M. Farring- 
ton's successful treatment by this method. 
He injects 50,000,000 bacteria at first treat- 
ment, gradually increasing the dose to 
100,000,000 at third treatment. The injec- 
tions should be made every third or fourth 
day. 

12. A Summary of Treatment 

To one who has read the outlines of 
treatment given in this book it will ap- 
pear that success in the treatment of hay- 
fever can be reached through several 
avenues, — through sera, surgical work, 
local application and internal medicines. 
Preparedness is the watchword of our 
country, and prevention is the keynote in 
the management of hay-fever. I there- 

[ 286 ] 



FORMS OF TREATMENT 

fore believe that hay-fever can be pre- 
vented by removing the stigma of neu- 
rotic inheritance and anatomical defects 
in youth and by observing the rules of 
the Hay-Fever Prevention Association, as 
outlined by Dr. Scheppegrell and quoted 
in this book. The careful study of pollen 
by Dunbar has advanced the possibility 
of cure by this means and will eventually 
bring about a more scientific adjustment 
of the remedy. At the present time, how- 
ever, treatment has not been satisfactory. 
A more extended study may give better 
results. Dunbar has caused many en- 
thusiastic workers to offer the results of 
their labors, and I have quoted Dr. H. 
Hays' experience with auto-serum, which 
should be more fully tested, and with 
him, the honest efforts of Dr. Manning, 
Dr. Alexander, and the earnest disciple 
of Dunbar, Dr. J. L. Goodale, whose con- 

[ 287 ] 



HAY-FEVER 

elusions as follows are the last words on 
pollen therapy. 

"Serobiological methods have shown 
the phylogenetic relationship of the dif- 
ferent plant-orders and -families. The ap- 
plication of these discoveries to the treat- 
ment of hay-fever by injection of plant 
proteids promises to assist in the selec- 
tion of the specific material required for 
a given case. Definite reactions are 
elicited in hay-fever by the pollen of the 
exciting plant when brought into contact 
with an abrasion of the skin. The in- 
tensity of these manifestations may be 
sensibly diminished by the repeated 'pa- 
renteral administration of the proteids in 
question. Coincident with the diminution 
in the skin reactions, there seems to occur 
an increased tolerance of the exposed 
mucous membrane to the pollens of the 
plants employed. Tollen therapy in hay- 

[288] 



FORMS OF TREATMENT 

fever may he regarded at the present 
time as a promising method of treatment, 
but its value and the permanence of its 
results remain still to be definitely es- 
tablished." 

To secure reasonable success it is im- 
portant that hay-fever patients should be- 
gin their treatment at least three or four 
weeks before the onset of the attack by 
the use of sedative solutions; a strict 
cleansing treatment being applied daily, 
if possible, to the nasal membrane to in- 
hibit the reflex. This local treatment 
should continue for several weeks. Many 
patients are relieved with the use of a 
weak solution of suprarenal, 1 : 10,000 in 
normal salt. Again, the antiseptic al- 
kaline solution, with an equal quantity of 
water, usually is sufficient; many are 
made better by the use of a weak Dobell's 
solution, and this is my choice of a solu- 

[ 289 ] 



HAY-FEVER 

tion. The frequency of a reaction causing 

congestion has rendered an otherwise 

valuable remedy undesirable. I therefore 

have better results with mild alkaline 

solutions of DobelPs, or the liquor anti- 

septicus alkalinicus. Again, many cases 

do well on an ointment of suprarenal in 

white vaseline. A small quantity placed 

in the nose will last longer and be more 

agreeable than the solution. In asthmatic 

patients the adrenalin chlorid in oil, used as 

a spray, is quite effective in selected cases. 

The danger in the use of cocain is too 

apparent to place it in the hands of the 

patient. Its use in office work is even 

questionable. 

Many internal remedies have been used, 

and, altho failure is frequent, I have 

found quinin, atropia, strychnin, anti- 

pyrin, iodids and thyroid among those 

most frequently prescribed. Quinin is 
[290] 



FORMS OF TREATMENT 

valuable in massive doses, both locally 
(snuffed up the nostril in powder form) 
and internally. The unpleasantness of 
the toxic effect is as great as the hay- 
fever itself, rendering it an undesirable 
remedy. The same can be said of anti- 
pyrin used internally. It must be given 
in large doses — seven to eight grains 3 
or 4 times daily for an adult. Its action 
is antispasmodic, and similar in effect 
to that in whooping cough. It is possible, 
and I believe this is true in many cases, 
it may act as an antitoxin to the irritant 
from the pollen, and in this way be of bene- 
fit when there are paroxysmal asthmatic 
symptoms. 

The iodids act well in small doses when 
the secretion is slight, but most patients 
are made worse by their use. Thyroid, 
in one grain doses, t. i. d., will increase 
the secretion, dilate the internal vessels 

[291] 



HAY-FEVER 

and thus relieve the nasal congestion. 
The use of thyroid is usually effective in 
patients over 50 and when there is gout 
or rheumatism. 

The drugs mentioned above are at best 
only palliative and in no sense curative. 
From the report of Emmerich and Leow 
we can hope to cure the chronic tendency 
of hay-fever {Jour. A. M. A., Jan. 17, 
1915). They report five cases that were 
broken up and the patients permanently 
freed from its grip by continued treat- 
ment with calcium chlorid. This paper 
furnished us with the only positive in- 
ternal remedy and is worthy of more 
extended trial. 



[ 292 i 



BIBLIOGEAPHY 



T293] 



BIBLIOGRAPHY 



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Schiller (J. B.), Das Sommerfieber am Mittelrhein im 
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Gordon (W.), Observations on the Nature, Cause, and 
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Ferber (R. H.), II. Der typische Friihsommer-Katarrh. 

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Med. Press and Circ, Dublin, 1868, iii, p. 477. 

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Kernig (W.), St. Petersb. med. Ztschr., 1869, xvii, 
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Zoja (G.) and De Giovanni (A.), Sopra la febbre del 
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Cooke (A. M.;, _i.ay-fever. Eclect. M. J., Cincin., 1870. 

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1872. 

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The Active Immunization of Hay-fever; A Pre- 
liminary Eeport. New York Med. J. (etc.), 1915, 
ci, pp. 229-232. 

Schmidt (K.), Ein Versuch., den Heuschnupfen durch 

Eb'ntgenstrahlen zu beeinflussen. Munchen. med. 

Wchnschr., 1915, lxii, p. 773. 
Scheppegrell (W.), Hay-fever-producing Weeds in the 

United States. Ohio Pub. Health Jl., Columbus, 1915, 

vi, pp. 325-329. 

Also Pub. Health Mich., Lansing, 1915, iii, pp. 462- 

466. 

Somme (J.), Et nyt hoifebermiddel ' ' Pollaccine ' ' Tid- 
sskr f. d. norske Laegefor., Kristiania, 1915, xxxv, 
pp. 107-110. 

Wood (F. M.), Hay-fever and Asthma. Chicago Med. 
Eecorder, 1915, xxxvii, pp. 453-459. 

1916. 

Fergus (J. F.), Vaccine Inoculations for Hay-fever. 
Glasgow Medical Jl., lxxxiv, pp. 344-352. 
[334] 



BIBLIOGRAPHY 

Hollopeter (W. C), Hay-fever; Its Prevention and 
Cure. 1916. Third Edition. 344 pp. 5 Illus. Funk 
& Wagnalls Company, New York and London. 

Noyes (Margaret L.), Report of Two Hay-fever Cases 
Treated with the Pollen Extract. JL A. M. A., Chi- 
cago, 1916, V. lxvi, No. 10. 

Oppenheimer (S.) & Gottlieb (M. J.), Pollen Therapy 
in Pollinosis. Medical Record, N. Y., March 11, 1916. 

Scheppegrell (Wm.), Hay-fever: Its Cause and Pre- 
vention. Jl. A. M. A., Chicago, 1916, V. lxvi, No. 
10, pp. 707-712. 

Strouse (Solomon) & Frank (Ira), Pollen Extracts and 
Vaccines in Hay-fever. Jl. A. M. A., 1916, V. lxvi, 
No. 10, pp. 712-715. 

Wilson (Harold), The Treatment of Hay-fever with 
Calcium salt. Jl. A. M. A., Chicago, 1916, V. xlvi, 
No. 10, pp. 715-716. 



[ 335 ] 



INDEX 



[337 ] 



INDEX 



Adenoids, 147, 168 
Adirondacks, immunity in, 

234 
Adrenalin, use of, 231, 260, 

290 
Aeroscope, 215 
Africa, southwest, cases in, 

216 
Age, influence of, 51, 121 
Albrecht, Th., 229, 238 
Albumin of pollen specific 

cause of hay fever, 211 
Alexander, I. H., 258 
Allen, Harrison, 34, 132 
American Hay ■ Fever - Pre- 

v e n t i o n Association, 

152, 161. Campaign of 

Education, 155 
Anaphylactic agent, 234 
Anaphylaxis, 229, 235 
Anemia, treatment of, 178 
Anesthesin, use of, 231 
Anglo - Saxon races, fre- 
quency of cases in the, 

111, 227 
Antitoxin, 192 
Areas, sensitive nasal, 34, 

35, 68, 71 
Arnold, 41 
Ascaris megalocephala as a 

cause, 98 
Ashhurst, Samuel, 130 

[3 



Asthma as a late symptom, 
62 
diagnosis from, 94 
treatment of, 121 
as sequel, 185 
complicating, 185 
Atlantic, cases on the, 114 
Australia, cases in, 113 
Autogenous vaccine, 150 
Auto serum, experiments 

with, 238 
Autoserum, method em- 
ployed in application, 
248 
Auto-suggestion, 50 



Bacteriologic study of nasal 
secretions, 103 

Ballinger, 149, 286 

Bastian, 98 

Beard, G. M., 13, 32, 47, 
48, 55, 63, 69, 75, 80, 
82, 93, 111, 115, 118, 
119, 120, 124, 125 

Beeeher, Henry Ward, cases 
in the family of, 118 

Benzoic acid, as a cause, 
88, 95 

Beschorner, 22 

Bibliography, 293 

Binz, C, 28 

Bishop, S. S., 36, 134, 138 
39 ] 



INDEX 



Blackley, Chas. H., 29, 31, 
39, 90, 95, 102, 103, 122, 
207 

Blackley, experiments of, 
90, 102 

Blood, alkalinity of, 135 

Blossoming dates, muta- 
bility of, 109 

Blue, Eupert, 160 

Bostock, J., 19, 24, 88 

Bosworth, 49, 50, 52, 63, 
72, 76, 82, 119, 127, 129, 
132, 134 

Botallus, 22 

Bronchial complications, 
treatment, 189 

Bronchitis complicating, 
189 

Broussais, 22 

Bullette, W. W., 83, 117 

C 

Calcium chlorid, 265 
Calcium salt treatment, 261 

conclusions as to, 273 
Camphor, use of, 170 
Canada, cases in, 115 
Capp, W. M., 70, 138 
Cardiac involvement, 65 
Caterpillars as a cause, 99 
Causes, xi, 38 

accepted, 87 

dust, 88, 93 

dust from books, 94 

enteric fever, 44 

exciting, 38, 87 

neurosis, 44 

pollen, 87, 102 

predisposing, 110 

rye, 89, 105 



Causes, ragweed, 105 
three, xi 
toxin, 40 
Causative factors, 31, 141 
Cavernous tissue, nasal, 73, 

128 
Chaveau, 111 

Children, frequent occur- 
rence in, x 
Children, hay-fever in, 77 
Chills, analogy to recur- 
rence of, 50 
Chocolate as a cause, 98 
Clark, Sir "Andrew, 36 
Cleansing of the nares, xii, 

23, 169 
Cocain, 105, 176 
Coffee as a cause, 97 
Complications, 84 
Conclusions on use of cal- 
cium salt, 273 
Conklin, 135 
Cornaz, 27 

Coryza, diagnosis from, 77 
Cottonwood fever, 117 
Cough as a symptom, 60 
Cough, persistent, between 

paroxysms, 63 
Cullen, 97 

Cutaneous eruptions as 
complications, 64 



Daly, W. H., 33, 130 
Darwin, 108 
Definition, 19 
Denmark, cases in, 113 
Derangement, internal, as 

cause, 240 
Diagnosis, 65, 84 



[340] 



INDEX 



Diatheses, theory, 45, 81 
Diet, 178, 183 
Discharges, nasal, 59 
Dobell's solution, use of, 

169, 289 
Drenger, 99 

Dunbar, W. P., 13, 191, 193 
Duration, 51, 52 
Dust as a cause, 46, 88, 93 
Dysphagia as a symptom, 

80 

E 
Ebstein, 135 
Elliotson, 23, 25 
Emanations from dry hay 

as a cause, 24, 96 
Emmerich, 261, 264, 292 
England, distribution of 

cases in, 94 
Environment, 142 
Erectile tissues, nasal, 69, 

72 
Eucain, 113 

Exciting causes, 39, 40 
Exercise, 178 
Experiments of Blackley 

on the pollen theory, 

102 
Eye-symptoms, 59, 213 



Factors, causative, xi 
Factors, essential, xii 
Farrington, P. M., 150, 286 
Fatigue as a cause, 24 
Feathers as a cause, 97 
Fever during an attack, 

56 
Fire Island, immunity in, 

234 



First recognition, 22 
Floyer, 23 

Fordyce, John A., 239 
Fox, Howard, 239, 243 
France, cases in, 113 
French, rarity of cases 

among the, 111, 113 
Fruit as a cause, 96 
Fungoid growth as a 

cause, 41 

G 

Gaslight, influence of, 92, 
96 

Gastro-intestinal causes, 
141, 143 

Genito-urinary organs, in- 
volvement of, 61 

Germans, rarity of cases 
among the, 111 

Germany, cases in, 113 

Gibbons, 82 

Goldenrod, in TJ. S., 219 

Goodale, J. L., 274 

Gottheil, Wm. S., 239, 246 

Grasses, varieties of, causa- 
tive, 96, 105, 106 

Grayson, C. P., 37, 139, 141 

Gream, G. Y., 25 

Green Mountains, immu- 
nity in, 234 

H 
Hack, W., 34, 62, 128, 131 
Haig, 135 
' l Hair-caterpillar asthma, ' ' 

99 
Handkerchiefs, effluvia 

from, as a cause, 97 
Hare, odor of, as a cause, 

98 



[341 ] 



INDEX 



Hay-fever-producing weeds, 
eradication of, 159 

Hays, Harold, 238 

Heart, involvement of, 65 

Heat as a cause, 88, 89, 90, 
96, 125 

Heligoland, immunity in, 
234 

Helmholtz, 28, 41, 96 

Heredity, influence of, 21, 
118, 228 

Herzog, 131 

History, 19 

Holmes, B. W., 37, 44, 57, 
75, 94, 109, 110, 122, 
123, 129, 133, 139 

Horses, odor of, as a cause, 
98, 99 

Hiiuerswolff, 100 

Hydrogen dioxid in treat- 
ment, 172 

Hydrotherapeutic treat- 
ment, 191 

Hygiene, 147 

Hygiene, personal, 168 

Hygienic treatment, 147 

Hypersensitiveness, 235 



Idiosyncrasy, influence of, 

21, 128 
Imagination, influence of, 

49, 101 
India, cases in, 113 
Indian, case in an, 111 
Indigestion as a cause, 143 
Ingals, 91, 176 
Insomnia as a symptom, 

61, 182 
Insurance, effect on, 80 



Intermittent fever, analogy 

to, 50 
Introduction, ix 
Ipecac as a cause, 23, 35, 

88, 97 
Italy, cases in, 113 
Itzigson, 97 
Ivy-poisoning, analogy to, 

107 



Jacobi, 111 



Kammann, O., 211, 214 
Kinnear, 127 

Koessler's last words, 252, 
254 



Labosse, 27 

Laforgue, 25 

Legislation for prevention, 

155 
Leucocytes, eosinophile, 252 
Liefmann, 212, 215 
Life insurance, effect on, 

80 
mode of, influence of, 122 
Light as a cause, 32 
Ligustrum vulgare in 

China, 216 
Linseed meal as a cause, 96 
Local disease theory, 37, 

130 
treatment, 167 
Locust-tree blossoms as a 

cause, 97 
Loew, 261, 264, 292 



[342] 



INDEX 



Longevity, effect on, 81 
Lycopodium as a cause, 88, 
97 



M 

MacCulloch, 25 
Macdonald, 36, 55, 83, 99, 

113 
Mackenzie, J. N., 34, 50, 

56, 64, 68, 101, 112, 

127, 131, 133 
Mackenzie, Morell, 35, 52, 

56, 65, 92, 100, 101, 

119, 120, 122, 128 
Males, prevalence in, 40, 

120 
Mango-tree as a cause, 107 
Manning, E. T., 254 
Marsh, E. J., 33, 105, 107 
Martin, Sidney, 187, 190 
Mattress as a cause, 100 
May apple as a cause, 97 
Mays, Thomas J., 135 
Menthol, use of, 170 
Micro - organisms in the 

nasal discharges, 40, 

41 
Moore, George, 29 
Morphin, use of, 231 
Morrell, cases in family, 

118 
Moschowitz, 252 
Mucous membrane, cleans- 
ing of, xiv, 168 
Mucous membrane, nasal, 

74, 168 
Mulberry blossoms as a 

cause, 97 
Muller, J., 143 



Murchison, 135 
Murrell, William, 99 
Mustard as a cause, 96 
Mutability of blossoming 
dates, 109 



N 

Name, origin of, 20, 23, 39 
Nasal abnormalities as 

causes, 38, 132 
symptoms, 58 
Nasopharynx, cleansing of, 

170 
Nasopharynx, sterilization 

of, 169 
Needles, MacBae, 243 
Negro, case in a, 112 
Nervous supply to the 

nares, 68 
Nervous system, etiologic 

factor, 32 
Nettle-rash as a complica- 
tion, 62 
Neurasthenic cases, 179 

treatment of, 179 
Neurotic element, xiii, 36, 

43, 118, 139 
Neurotic temperament, x, 

118 
theory, 36, 44 
Neusser, 252 
New Orleans, work done 

there, 165 
New Zealand, cases in, 113 
Norway, cases in, 113 
Nose, coldness of, 30, 55 
Nutrition, defective, a 

cause, 140 



[343] 



INDEX 



Oak as a cause, 98 
Obstruction of the nares as 

a cause, 132 
Occupation, influence of, 

124, 228 
Occurrence, time of, 27, 

47, 48, 52 
Ocean, cases on the, 107, 

108 
Odors of fruits and flowers 

as causes, 96 
Ohls, 176 

Onset, period of, 48 
Onset, symptoms of, 54, 56, 

58 
Origin, 39 

Origin, nervous, first ad- 
vanced, 28 
Origin of the name, 20, 23 
Ozone as a cause, 32, 88, 95 



Parry, C. L., 23 

Pathology, 65, 84 

Patton, 208 

Peaches, odor of, as a 
cause, 19, 100 

Periodicity, 19, 46 ; 53, 56 

Personal susceptibility, 35 

Phoebus, P., 26, 32, 49, 88, 
91, 95, 101, 120, 122 

Phylacogen, mixed infec- 
* tion, 260 

Phylacogen, use of, 258 

Pirrie, W., 28, 32, 51, 89, 
91, 113 

Pneumonia as a complica- 
tion, 64 



Podophyllum as a cause, 97 
Pollantin, 192 
Pollantin, R., 235 
Pollen albumin, injection 
of, producing disease, 
223 
albumin, reaction to, 227 
albumin, specific cause 

of hay-fever, 211 
as causative factor, 31 
dried, active on libera- 
tion, 202 
extracts, method of pre- 
serving, 274 
first reference to, 31 
kinds of, 105 
method of obtaining, 103 
theory, 31, 87 
therapy, 274 

therapy, conclusions, 288 
toxin, true, 254 
toxins, 193 
Polypi, Bosworth 's views 

relative to, 138 
Potassium iodid, 190 
Prater, Augustus, 25 
Predisposing causes, 20, 21, 

110 
Predisposition, individual, 

280 
Predisposition, individual, 

as factor, 220 
Preface, v 
Premonitory symptoms, 44, 

54, 89 
Preventive measures, 147 
Preventive treatment, 151 
Prince, M., 50, 51, 119, 126 
Proctor, Richard, case of, 

90 
Prognosis, 65, 80 



[344] 



INDEX 



Prophylactic treatment, 
155, 176 

Protoplasmic substance as 
a cause, 43 

Pruritis ani during an at- 
tack, 58 

Psoriasis, differentiation 
from, 241 

Psychic influence in the 
causation, 49, 101 

Puis© during an attack, 58 

Q 

Quinin solution as a rem- 
edy, 28, 41 
Quinquaud, 135 

E 

Eace, influence of, 111 

Eagweed as an exciting 
cause, 42, 105 

Eagweed, cultivation as 
exterminator, 163, 164 

Eagweed, in U. S., 219 

Eamadge, 25 

Eectum, involvement of, 61 

Eecurrence, period of, 49 

Eegions of the nasal cavi- 
ties, 66 

Eeport of cases, 248, 249, 
250, 251, 267, 268, 269, 
270, 271, 272 

Eesistance, lowered, x 

Eesistance, lowered, factor 
in, 39 

Eest, 178 

Eiedlin, 23 

Einger, 99 



Eoberts, W. C, 30, 55 
Eobinson, B., 128 
Eoe, J. O., 34, 70, 131 
Eoman wormwood as an 

exciting cause, 47 
Eussia, cases in, 113 



S 

Sajous, C. E. de M., 34, 44, 
54, 64, 66, 70, 111, 119, 
131 

Salol capsule in, 187 

Salter, Hyde, 26, 98 

Sandalwood in, 187 

Schadle, 150 

Scheppegrell, 152 

Scotland, cases in, 113 

Sea, cases at, 108 

Sensitive areas of the 
nares, 45, 68, 171 

Sequelae, 185 

Serum, method of prepar- 
ing, 243 
nasal, 59 
use of, 191 

Sex, influence of, 120 

Shaw, cases in family, 119 

Sinusitis, relation to, 149 

Skin eruptions, 64 

Skin reactions, 278, 283 

Smell, involvement of, 59, 
65 

Smith, Abbotts, 27, 108, 
110, 114 

Smith, Ward, 96 

Sneezing in, 58, 267 

Snuff in treatment, 174 

Solis-Cohen, S., 127, 129, 
188 



[3451 



INDEX 



South America, cases in, 
113 

Spain, cases in, 113 

Spontaneous disappearance 
of the recurrences, 83 

Sterilization of the nares, 
169 

Sticker, 202 

Strangways, W. F., 42 

Sunlight, influence of, 25, 
92, 96 

Sunshine as a cause, 24, 26 

Suprarenal extract, 176 

Suprarenal gland in treat- 
ment, 176 

Suprarenal tablet in treat- 
ment, 174 

Surgical treatment, 285 

Swain, H. L., 176 

Swallowing, difficult, 80 

Sweden, cases in, 113 

Symptoms, 19, 53, 54, 56, 
65 

Synonyms, 9, 19 

Systemic treatment, 178 



Taste, involvement of, 59, 

65 
Tea-drinking, influence of, 

112 
Temperature during an at- 
tack, 57, 61 
Term first used, 20, 23 
Theory, idiosyncrasy, 34 
local, 37, 132 
neurotic, 36, 44, 139 
pollen, 32 
uric-acid, 134 



Thornwaldt, 133 

Three predisposing causes, x 

Timaeus, 23 

Time of occurrence, 27, 47, 

48, 52 
Tomatoes as a cause, 98 
Tonsils, 148, 168 
Toxin as a cause, 40 

dried pollen, active on 
liberation, 202 

true, pollen as, 254 
Treatment, 147 

calcium chlorid, result of, 
268 

calcium salt, 261 

cleansing nostrils, 170 

Dobell's solution, 169 

hydrogen dioxid, 172 

local, 167 

nasal applications, 167 

normal salt, use of, 173 

pollen therapy, 274 

preliminary local, 172, 
176 

prophylactic, hygienic, 
and systemic, 178 

scrubbing, of nostrils, 
172 

surgical, 285 

Trosseau, 100 
Types, 54 

according to duration, 52 



United States, autumnal 
variety prevalent, 217 

United States, distribution 
of cases in the, 53 



[ 346] 



INDEX 



Uric-acid theory, 130, 134, 
137, 139 



Van Helmont, 22 
Van Sweringen, 188 
Vasomotor control, nasal, 
127 

susceptibility, theory of, 
126 

Vibrios in the discharges, 
29 

Vogel, 96 

Voice, changes in, 61, 148 



W 

Walshe, 27, 107, 114 

Watermelons as a cause, 98 

Watson, 26 

Sir Thomas, 97 

Weeds, removal of, 157, 
159, 160 

What hay-fever is, 19 

White Mountains, immu- 
nity in, 31, 234 

Wilson, Harold, 261 

Wilson, J. C, 107 

Woodward, 202 

Wright, E. W., xiv 

Wyman, Morrill, 30, 31, 65, 
106, 111, 115, 118, 120, 
122 



[347] 



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